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Outcome of cataract surgery in central India: a longitudinal follow-up study. An epidemiological follow-up study of patients who had intracapsular cataract extraction in a voluntary hospital and its associated eye camps in Central India has for the first time evaluated the outcome one year after surgery in terms of visual acuity, use of spectacles, and improvement in income and mobility. The findings indicate that under these fairly typical conditions, 92% of the cases have adequate vision of 6/18 or better one year after surgery. Information on high usage of spectacles and on considerable improvements in income and mobility after cataract surgery is also reported. The outcome for patients operated upon in eye camps was almost as favourable as for those operated upon in hospital. Although the small differences are not statistically significant, the comparative findings require cautious interpretation and give rise to the epidemiological issues which are briefly discussed in this paper.
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Haemostatic changes in the loin pain and haematuria syndrome: secondary to renal vasospasm? Twenty-five patients (seven male, 18 female) were diagnosed as having the loin pain and haematuria syndrome. Presenting symptoms were either loin pain alone or pain associated with macroscopic or microscopic haematuria, and were longstanding, having been present for mean of 9.3 years in males, and 10 years in females. Ten patients described symptoms of passing gravel or renal stones but these were only demonstrated radiologically in two patients. Investigation of all patients showed anatomically normal renal tracts, normal renal function, and no significant proteinuria. Phase-contrast microscopy during episodes of haematuria revealed dysmorphic red cells in all 10 patients studied. Renal biopsies were performed in 20 patients and showed no glomerular pathology, but arteriolar and arterial hyalinosis was seen in 13 of 20 (65 per cent), fibro-elastosis in larger vessels in eight of 20 (40 per cent) and red blood cells in tubules in 13 of 20 (65 per cent) patients. The histological appearance in vessels was similar to that seen in cyclosporin A nephrotoxicity and would be consistent with the hypothesis that regional vasospasm occurs in the cortical circulation. Haematological studies in 22 patients, when compared with age and sex matched controls, showed the presence of circulating platelet aggregates, elevation of plasma beta-thromboglobulin (p less than 0.001), and increased platelet aggregation in response to serotonin and ADP (p less than 0.05 and p less than 0.03, respectively). Plasma concentrations of D dimer (p less than 0.02) and C-reactive protein (p less than 0.03) were also significantly elevated in the patient group. There was no deterioration of renal function during a mean observation period of 3.7 years and no patients developed proteinuria. Treatment was largely supportive; seven patients with intractable loin pain underwent surgical denervation with the relief of pain in four.
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Attenuation of suxamethonium myalgias. Effect of midazolam and vecuronium. We studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone, N2O, isoflurane anaesthesia. Four groups of 20 patients each were pretreated with saline (group 1), tubocurarine 0.05 mg/kg (group 2), vecuronium 0.006 mg/kg (group 3), or midazolam 0.025 mg/kg (group 4), followed by suxamethonium 1.5 mg/kg. Group 5 received only vecuronium 0.1 mg/kg as relaxant (no suxamethonium). Fasciculations were graded, and postoperative myalgias rated on the first and third postoperative days. In groups 1-5 the incidence of fasciculations was 95, 15, 25, 95 and 0%; the incidence of myalgias on the first day after operation was 70, 45, 65, 75 and 60%, and on the third day after operation 20, 5, 20, 20, and 5%, respectively. We conclude that pretreatment with vecuronium, but not midazolam, decreases the incidence of fasciculations after suxamethonium (p less than 0.05) and that in this patient population, postoperative myalgias appear to be unrelated to the use of suxamethonium.
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A case of unilateral posterior ischemic optic neuropathy after radical neck dissection. We present a case of unilateral posterior ischemic optic neuropathy after bilateral radical neck dissection. Etiologic factors are discussed.
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Hypothermia. Safe and efficient methods of rewarming the patient. Hypothermia, a relatively common problem in the winter months, can cause significant morbidity. It presents in a variety of situations and affects a wide age range. Diagnosis requires a high index of suspicion, because the symptoms, which are primarily related to the central nervous system, are not distinctive. Appropriate management requires accurate measurement of core body temperature. Treatment is centered on rewarming the patient safely and efficiently while providing other supportive measures. Care should be taken to avoid arrhythmias. Simple precautions greatly reduce the risk of hypothermia.
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Recurrence of resected esophagogastric adenocarcinoma: results of re-resection. Isolated local recurrence following potentially curative resection for carcinoma of the esophagus or esophagogastric junction does not necessarily imply pending systemic disease and early demise. While radiation alone or in combination with chemotherapy is standard treatment for such patients, resection is another available option. Resection may also be a consideration should localized disease persist after non-operative therapy in the absence of metastases. A 5 year retrospective review was performed examining 204 resections performed prior to 1989. Only 5 patients underwent resection of locally recurrent esophagogastric (EG) adenocarcinoma during this period. No squamous carcinoma recurrences were resected. One patient is well 15 months later while another died at 18 months of other causes without recurrence. Recurrence after re-resection occurred at 8, 11, and 24 months in the 3 other patients. Although there were no postoperative deaths, major complications occurred in 4 patients. All 5 patients swallowed normally after operation.
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Bone weakness after the removal of plates and screws. Cortical atrophy or screw holes? Bone weakness leading to refracture is a recognised complication of the removal of rigid fixation plates. We have used partially demineralised rabbit tibiae to simulate atrophic changes and to determine whether weakness is due to atrophy or to residual screw holes. Partial demineralisation and a screw hole each reduced maximum bending moment. However, energy absorbing capacity was little affected by demineralisation, but was reduced to 50% by a single drill hole. Residual screw holes are a considerably more important cause of bone weakness after plate removal than is cortical atrophy.
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Long-term psychosocial adjustment to coronary artery disease. Personality hardiness, which has been conceptualized as a potential internal resource facilitating stress resistance, was examined in conjunction with Type A behavior, perceived family cohesion and adaptability, and sociodemographic and medical variables to assess the independent differential correlations of these factors with long-term psychosocial adjustment to coronary artery disease. One hundred twenty-eight patients completed the third generation Hardiness Scale, together with questionnaires measuring Type A behavior, perceived family cohesion and adaptability, and psychosocial adjustment to illness. The results showed that personality hardiness was the most salient correlate of psychosocial adjustment. High hardiness scores were associated with good adjustment to the various life domains. Angina severity accounted for the variance in social domains, but not the psychologic distress domain. Type A behavior, both dimensions of perceived family dynamics, and the sociodemographic variables did not have a significant role in explaining the variance in psychosocial adjustment. We conclude that personality hardiness could serve as a valid indicator of long-term psychosocial adjustment in patients with coronary artery disease.
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Intestinal vascular sensitivity to vasopressin in portal hypertensive rats. The intestinal vascular responsiveness to arginine vasopressin was evaluated in rats with chronic portal hypertension. Male Sprague-Dawley rats were made portal hypertensive by stenosis of the portal vein. Ten to twelve days after the induction of chronic portal hypertension, the responsiveness of the small intestinal circulation to cumulative doses of vasopressin was evaluated using an isolated pump-perfused small intestinal preparation. The ED50 for maximal vasoconstriction was increased twofold in portal hypertensive rats compared with control rats. To determine if the impaired responsiveness to arginine vasopressin was related to the hyperglucagonemia of chronic portal hypertension, plasma glucagon levels were elevated in normal rats to levels previously measured in portal hypertensive rats (i.e. approximately 450 pg/mL), and the dose response studies were repeated. Glucagon significantly attenuated the responsiveness of the intestinal vasculature to vasopressin. Equipotent doses of nitroprusside also attenuated intestinal vascular responsiveness to vasopressin. The results indicate that there is a reduced vascular sensitivity to vasopressin in the intestine of portal hypertensive animals and suggest that elevations in circulating vasodilators in portal hypertensive conditions may partially explain this altered vascular responsiveness.
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Myocardial revascularization for the third time. Clinical characteristics and follow-up. Twenty-five patients presenting for a third revascularization procedure were retrospectively reviewed at Loyola University Medical Center, Maywood, IL. This represents 0.5 percent of the total revascularization cases over a five-year period extending from 1985 through 1989. Perioperative mortality was none, and seven complications occurred in six patients. Internal mammary arteries were used for revascularization in 60 percent of this group. Follow-up reveals that only one patient has died secondary to an arrhythmia. All patients except one are symptomatically improved, and 18 patients remain angina free at a mean follow-up of 22.3 months. It is therefore concluded that patients are clinically improved with a third revascularization, and this procedure should be offered as an effective means of treatment.
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Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery. Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation.
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Cerebrovascular complications of inflammatory bowel disease. There is an increased incidence of central nervous system thromboembolic events in young patients with inflammatory bowel disease. A 33-yr-old woman previously diagnosed with pseudotumor cerebri suffered superior sagittal and transverse sinus thromboses during a severe flare of ulcerative colitis. These were documented on contrast computed tomographic (CT) and magnetic resonance imaging (MRI) scans. Stroke may be more common in patients with ulcerative colitis than in patients with Crohn's disease; arterial disease is more prevalent than venous and dural sinus disease, and is correlated with an active phase of inflammatory bowel disease. It is difficult to assess whether there is a relationship to concurrent steroid use, and a consistent relationship to duration of inflammatory bowel disease or to other extraintestinal manifestations is not apparent.
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Uses and limitations of transthoracic echocardiography in the assessment of atrial septal defect in the adult. Two-dimensional and color Doppler echocardiography accurately detected the presence of an atrial septal defect (ASD) in 47 of 50 adults (mean age 40 years) confirmed by surgery or cardiac catheterization, or both. It correctly categorized all patients with ostium secundum and ostium primum ASD but misdiagnosed 3 of 5 patients with surgically proven sinus venosus ASD. The shunt flow volume across the ASD was calculated with the standard Doppler equation, and assuming the ASD to be circular correlated with shunt flow volume obtained by cardiac catheterization (r = 0.74). The maximum width of the color flow signals moving across the ASD was taken as its diameter. Mean flow velocity was determined either by placing a pulsed Doppler sample volume parallel to the flow across the ASD as visualized by color Doppler or by color M-mode examination, which allowed determination of flow velocities using a previously validated method that incorporates a computer analysis of pixel color intensity. The pulmonary to systemic blood flow ratio obtained by color-guided conventional Doppler interrogation of the left and right ventricular outflow tracts correlated poorly with cardiac catheterization results (r = 0.38). In patients with associated tricuspid regurgitation, the peak systolic pulmonary artery pressure obtained by color Doppler-guided continuous-wave Doppler correlated well with that obtained at cardiac catheterization (r = 0.89). The maximum color Doppler jet width of the flow across the ASD poorly correlated with ASD size estimated at surgery (r = 0.50).
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Synchronous diffuse well-differentiated lymphocytic lymphoma and gastric adenocarcinoma presenting as splenomegaly and iron deficiency anemia. Diffuse well-differentiated lymphocytic lymphoma (D-WDLL) and chronic lymphocytic lymphoma (CLL) represent closely related neoplasms which may have indolent courses. Dating back more than one century, reports of associated second primary malignancies continue to intrigue clinicians. A case of synchronous D-WDLL and gastric adenocarcinoma, presenting as splenomegaly and iron deficiency anemia, is presented. The case and literature are reviewed.
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Severe lidocaine intoxication by cutaneous absorption. A severe lidocaine intoxication by cutaneous absorption is described. Data are presented to show a significant absorption of lidocaine through diseased skin when lidocaine cream is used as a local anesthetic. Awareness of this route of intoxication might be important in patients in whom neurologic or psychiatric symptoms develop while large amounts of lidocaine cream are being used.
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The role of the chest roentgenogram in febrile neutropenic patients. In a retrospective review of patients with neutropenia and fever, we sought to determine how often roentgenograms detected pulmonary disease, especially pneumonia, not suggested by signs and symptoms. Further, we sought to determine how often therapy was changed as a result of roentgenographic findings. Overall, 41 (22%) of 187 chest roentgenograms obtained during initial febrile episodes, recurrent fevers, or persistent fevers were abnormal. While most patients had signs and symptoms suggesting the presence of pulmonary disease, 17% had roentgenographic abnormalities detected in the absence of such findings. During initial febrile episodes, therapy was not changed in response to findings on the chest roentgenogram. However, during episodes of persistent or recurrent fever, findings on chest roentgenograms led to changes in therapy in eight (61%) of 13 episodes of which six (40%) resulted in clinical improvement. Chest roentgenograms were therefore found to be an important diagnostic tool in evaluating recurrent or persistent fever in the neutropenic patient but of little use during initial febrile episodes.
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Transcranial Doppler determination of cerebral perfusion in patients undergoing CPR: methodology and preliminary findings. STUDY OBJECTIVES: To correlate cerebral arterial blood velocity measurements as determined by transcranial Doppler ultrasound with various resuscitation maneuvers performed in an uncontrolled manner in a series of cardiac arrest patients undergoing standard resuscitation. TYPE OF PARTICIPANTS: Any patient undergoing resuscitation for a nontraumatic cardiac arrest was eligible for the study. INTERVENTIONS: Resuscitation was carried out while flow velocities were monitored in various intracranial arteries by transcranial Doppler ultrasound. Vessel identification was based on the angle and depth of insonation. MEASUREMENTS AND MAIN RESULTS: The internal carotid artery was located more consistently than either middle cerebral or ophthalmic arteries and provided superior waveforms for analysis. Alterations in flow velocity were noted and correlated to various therapeutic interventions. Flow velocities were 70% of normal during the early phase of resuscitation but deteriorated over time until there was no evidence of net forward flow. Even early in CPR, flow was demonstrated only during systole. CONCLUSION: Transcranial Doppler ultrasound appears to be a potentially promising means of determining cerebral flow in patients undergoing CPR.
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Cytoreductive hepatic surgery for neuroendocrine tumors. We retrospectively reviewed 37 patients who underwent hepatic resection between 1970 and 1989 to evaluate the role of cytoreductive hepatic surgery in patients with metastatic neuroendocrine tumors (carcinoid, 24; islet cell, 13). Seventeen resections were curative (no gross residual tumor); nine patients had symptomatic endocrinopathies and seven patients had symptoms caused by the primary tumor. Eight of nine patients with symptomatic endorcrinopathies obtained complete relief of symptoms; five are alive with no evidence of disease at 2 to 82 months (mean, 26 months). Six of seven patients with symptoms caused by the primary tumor obtained complete relief; five are alive with no evidence of disease at 5 to 28 months (mean, 14 months). One symptom-free patient underwent curative hepatic resection 5 years after abdominoperineal resection for a rectal carcinoid. Twenty resections were palliative (gross residual tumor); 16 patients had symptomatic endocrinopathies and 4 patients had symptoms caused by the primary tumor. Eight of 16 patients with symptomatic endocrinopathies obtained complete relief; five are alive at 2 to 30 months (mean, 11 months), with a mean duration of complete relief of 6 months (3 to 12 months). All four patients who underwent resection for symptoms caused by the primary tumor obtained complete relief; two are alive and symptom free at 10 and 101 months. Our experience suggests that curative surgery should be considered in all patients with completely resectable metastatic disease and that palliative surgery, despite the short duration of complete relief, should be considered in selected patients because it delays and may reduce the subsequent need for medical therapy.
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Hepatic vein reconstruction for preserving remnant liver function. Hepatic malignancies often infiltrate to the major hepatic vein. Recently, we performed hepatic resection combined with hepatic vein reconstruction for preserving remnant liver function in three such patients. One patient had a saphenous vein graft. Postoperative liver function of the patients who underwent hepatic vein reconstruction was compared with those of eight patients who underwent hepatic resection of segments VII and VIII. The right hepatic vein in four of them was resected and in the remaining four was preserved by skeletalization using an ultrasonic aspirator. Although four patients with right hepatic vein resection showed severe lowering of liver function after surgery, the postoperative course of patients with preservation or reconstruction of the right hepatic vein maintained good liver function. Liver regeneration of three patients with hepatic vein reconstruction was good on computed tomography. Besides this report, to our knowledge, there is no other report of hepatic vein reconstruction for preserving the remnant liver function. Problems with hepatic resection combined with hepatic vein reconstruction are discussed. We conclude that hepatic vein reconstruction is one of the means for extending indication of the malignant tumor resection of the liver.
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Methamphetamine. Stimulant of the 1990s? During the past several years, the use of a smokable form of methamphetamine hydrochloride called "ice" has increased rapidly. The heaviest use has occurred on the West Coast and in Hawaii. Many regional emergency departments treat more methamphetamine users than cocaine-intoxicated patients. The ease of synthesis from inexpensive and readily available chemicals makes possible the rampant abuse of a dangerous drug that can produce a euphoria similar to that induced by cocaine. Clinicians should be familiar with the medical effects and treatment of acute methamphetamine toxicity.
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Initial airway function is a risk factor for recurrent wheezing respiratory illnesses during the first three years of life. Group Health Medical Associates. We recently reported a significant relationship between lung function measured prior to any lower respiratory tract illness and subsequent wheezing illnesses during the first year of life (N Engl J Med 1988; 319:1112-7). Follow-up has continued for this group of infants during the second and third years of life. When compared with never wheezers, infants who wheezed during the first year of life and had at least one additional lower respiratory illness had 22% lower initial levels of an indirect index of airway conductance derived from the shape of tidal breathing curves (p less than or equal to 0.01), 22% lower respiratory conductance (p less than or equal to 0.05), 25% lower maximal flows at the end-expiratory point (p less than or equal to 0.01), and 10% lower functional residual capacity (p less than or equal to 0.05). Infants who wheezed only once during the first 3 yr of life or who started wheezing during the second year of life had normal tidal breathing curves but significantly lower maximal expiratory flows (p less than or equal to 0.05). Their functional residual capacity was also lower than that of never wheezers (p less than or equal to 0.05). We conclude that diminished initial airway function may be a predisposing factor for recurrent wheezing respiratory illnesses starting in the first year of life. Infants who will have only one wheezing respiratory illness or who will start wheezing after the first year of life seem to have lower levels for some but not for all lung function tests performed in this study.
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Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer. In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure.
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Cell lineage markers in human pancreatic cancer. The normal pancreas consists of three major cell types or lineages that share a common embryologic origin from pluripotent endodermal precursors. The type of cell that undergoes neoplastic transformation to form a pancreatic carcinoma is controversial and may influence the phenotype and biologic behavior of the tumor. In this study, immunohistologic techniques were used to determine the cell lineage differentiation expressed in 29 primary exocrine pancreatic adenocarcinomas, five metastatic exocrine pancreatic adenocarcinomas, and five islet cell neoplasma. Specimens of normal pancreas and chronic pancreatitis were used for comparison. The cell lineage markers consisted of monoclonal and polyclonal antibodies against trypsin and lipase (acinar cells); secretory component, carbonic anhydrase II, and pancreatic cancer mucin SPan-1 (ductal cells); and chromogranin-A and somatostatin (islet cells). The expression of carcinoembryonic antigen (CEA) and lysozyme were also determined. This collection of markers allowed the differentiation between acinar, ductal, and islet cells of normal pancreas and chronic pancreatitis specimens. The expression of cell lineage markers in islet cell tumors was homogeneous and restricted to chromogranin-A. In contrast, the expression of these markers in primary and metastatic exocrine pancreatic adenocarcinomas was variable. Reactivity with monoclonal anti-CEA was absent in normal pancreas, and was present in 83% of chronic pancreatitis specimens as well as 90% of exocrine pancreatic adenocarcinomas. In addition, lysozyme reactivity was absent in normal pancreas; however, lysozyme was expressed in one case of chronic pancreatitis, 17 cases of primary carcinoma, and three cases of metastatic carcinoma. These findings support the concept that the original transformed cell type in many pancreatic exocrine carcinomas resemble endodermal "stem cells" that retain the capability of differentiation along more than one cell lineage pathway.
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Diagnosing breast carcinoma in young women OBJECTIVE--To assess the individual and combined diagnostic accuracy of clinical examination, mammography, and fine needle aspiration biopsy in young women with breast cancer. DESIGN--Analysis based on case notes of patients presenting with breast cancer during 1971-89. SETTING--A combined breast clinic. PATIENTS--Consecutive series of 81 women aged less than 36 with histologically proved breast cancer presenting with a discrete mass over 19 years. MAIN OUTCOME MEASURES--Results of clinical examination, xeromammography or conventional mammography, fine needle aspiration biopsy, and examination of tissue removed by surgery. RESULTS--The clinical diagnosis was correct in 47 women and radiography in 35. Fine needle aspiration biopsy was correct in 47 of the 63 women in whom it was successfully performed. Fine needle aspiration was significantly more accurate than mammography (78% v 45%, p less than 0.01). Ten (16%) patients had negative results on clinical examination, mammography, and fine needle aspiration. CONCLUSION--Mammography alone seems inadequately sensitive to detect breast cancer in young patients. When all investigations give negative results excision biopsy is the only way of obtaining a definitive diagnosis.
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Hemorrhoids. A practical approach to an aggravating problem. Although hemorrhoids are considered a minor medical problem, they may cause considerable discomfort and anxiety. Fortunately, treatment is often simple and surgery is rarely necessary. In this practical article, Dr Cocchiara describes internal and external hemorrhoids, a classification system, and treatment choices based on the degree of involvement.
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Effect of beta-adrenergic blocking agents on the circadian occurrence of ischemic cardiovascular events. Clinical observations suggest that beta-adrenergic blocking agents can modify the circadian occurrence of a variety of ischemic events. Morning awakening is associated with a rapid increase in blood pressure and pulse, serum catecholamine content and platelet activation, at a time of decreased blood thrombolytic activity. Beta-adrenergic blocking agents have the potential to modify many of these events. Current data indicate that these agents modify blood pressure and pulse, but do not prevent their early morning increase. In addition, beta-adrenergic blocking agents decrease ventricular ectopy and its circadian variation. Recent studies in humans indicate, however, that metoprolol does not affect the circadian increase in platelet activity or serum catecholamines. The specific mechanism by which beta blockers affect the circadian occurrence of ischemic events remains uncertain.
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Catastrophic thrombosis of porcine aortic bioprostheses. Hemodynamically critical thrombotic stenosis of porcine bioprosthetic valves in the aortic position without thrombotic predisposition is rare. Two patients at our institution abruptly manifested thrombotic stenosis of porcine bioprosthetic valves in the aortic position within 3 months of implantation without apparent predisposing factors. Clinicians should consider this rare but catastrophic complication in the appropriate setting.
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Surgical management and prognosis of renal cell carcinoma invading the vena cava. A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerota's fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.
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Lack of prognostic value of syncope in patients with Wolff-Parkinson-White syndrome Syncope in patients with Wolff-Parkinson-White syndrome may be considered a premonitory event heralding the future development of sudden death. Therefore, the clinical and electrophysiologic data of 101 patients with Wolff-Parkinson-White syndrome referred for invasive evaluation of known arrhythmias were reviewed to assess the incidence and clinical relevance of syncope. Thirty-six patients reported the occurrence of one or more syncopal episodes (group 1) and 65 patients had no syncope (group 2). These two groups did not differ significantly with regard to age, gender, incidence and characteristics of arrhythmia, clinical history, frequency of arrhythmic events and presence of associated cardiac disease. There were 10 patients in group 1 and 12 in group 2 who had ventricular fibrillation. There were no statistical differences between the two groups with respect to the effective refractory period of the right atrium, atrioventricular node, accessory pathway and right ventricle. Furthermore, no differences between the two groups were noted with respect to cycle length of circus movement tachycardia, mean heart rate during atrial fibrillation, and minimum RR interval during atrial fibrillation. In addition, the accessory pathway location was not significantly different between group 1 and group 2. The occurrence of syncope could not be predicted from any electrophysiologic finding and this symptom had a low sensitivity and specificity for recognition of dangerous rapid heart rates. Furthermore, the prognostic value of syncope was less accurate and predictive than the shortest RR interval during atrial fibrillation and the anterograde effective refractory period of the accessory pathway for aborted sudden death occurrence.
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Microscopic pulmonary tumor embolism causing subacute cor pulmonale: a difficult antemortem diagnosis [published erratum appears in Mayo Clin Proc 1991 Apr;66(4):439] Microscopic pulmonary tumor embolism is difficult to diagnose. The most common initial clinical symptom is subacute progressive dyspnea, and the initial laboratory evaluation typically shows hypoxemia in a patient with clear lung fields on a chest roentgenogram. Another distinguishing feature may be hepatic abnormalities. In general, pulmonary angiography discloses no evidence of emboli, but multiple subsegmental peripheral perfusion defects are noted on ventilation-perfusion lung scans. The diagnosis of microscopic pulmonary tumor embolism can be confirmed by open-lung or transbronchial lung biopsy or by microvascular pulmonary cytology, a less invasive procedure that could be performed at the time of pulmonary angiography. Herein we describe two patients with unsuspected microscopic pulmonary tumor embolism that eventuated in subacute cor pulmonale and death. These cases illustrate the characteristic findings of this entity and emphasize the need for early diagnosis.
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Prevention of hypotension following spinal anaesthesia for elective caesarean section by wrapping of the legs. Twenty-four parturients undergoing elective Caesarean section were allocated randomly to have the legs wrapped with elasticated Esmarch bandages immediately following spinal anaesthesia or to serve as controls. Significant hypotension (systolic arterial pressure less than 100 mm Hg and less than 80% of baseline value) was treated with i.v. ephedrine in 5-mg boluses. Leg wrapped patients had a significantly (P = 0.0033) lower incidence (16.7%) of hypotension than controls (83.3%). Only two patients in the leg wrapped group required ephedrine compared with 10 in the control group. Systolic arterial pressure was significantly (P less than 0.05) less in control subjects at 4, 5 and 6 min following spinal injection. No patient in the leg wrapped group became hypotensive following removal of the elasticated bandages.
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Lipolytic factors associated with murine and human cancer cachexia. We have identified a lipolytic factor in extracts of a cachexia-inducing murine carcinoma (MAC16) that shows characteristics of an acidic peptide and appears to be composed of three fractions of apparent molecular weights corresponding to 3 kd, 1.5 kd, and 0.7 kd, as determined by exclusion chromatography. Material with identical chromatographic and molecular weight characteristics was also present in the serum of patients with clinical cancer cachexia but absent from normal serum, even under conditions of starvation. The MAC16 lipid factor, when injected into animals bearing the non-cachexia-inducing tumor MAC13, was capable of inducing weight loss without a significant reduction in food intake. Similar lipolytic material, although in lower concentration, was also found in the MAC13 tumor extracts. These findings suggest that cachexia may arise from the enhanced expression of a lipolytic factor associated with tumor cells.
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Benefit of ketotifen in patients with eosinophilic gastroenteritis. PURPOSE: Eosinophilic gastroenteritis (EG) is a rare condition of unknown etiology characterized by vomiting, diarrhea, protein-losing enteropathy, and eosinophilic infiltration of the gastrointestinal mucosa. The potential association of EG with allergy and related mast-cell release of mediators led us to evaluate the ability of an antihistamine drug to modify the course of the disease. PATIENTS AND METHODS: Six patients with protracted gastrointestinal symptoms were diagnosed with EG because of histologic evidence of predominantly eosinophilic infiltrates in the gastrointestinal mucosa. Each patient was treated in an open trial for 12 months with ketotifen (Zaditen), an antihistamine of the H1 class that is known to stabilize mast cells. RESULTS: All six patients improved clinically; four also gained weight. Total serum IgE levels decreased after 4 to 6 months of therapy. Clearing of eosinophilic infiltrates was documented in the four patients who underwent follow-up mucosal biopsies. CONCLUSION: We conclude that ketotifen treatment represents a safe and effective alternative to traditional systemic corticosteroid therapy for treatment of EG.
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Acute and chronic bioeffects of single and multiple doses of piezoelectric shockwaves (EDAP LT.01). Piezoelectric second generation lithotriptors are an established means of administering extracorporeal shockwave lithotripsy (ESWL) enabling treatment to be performed without anaesthesia or analgesia, but higher shockwave doses and multiple or staged treatment are frequently required. The bioeffects of this modality of ESWL, therefore, require further assessment. Seven experimental groups of adult male rabbits were treated using the EDAP LT.01 in order to determine the acute and chronic bioeffects of clinical dose, excess dose, divided excess dose, high frequency and multiple treatment (X10) piezoelectric shockwaves (PSW). Renal function was measured before and after treatment using mercaptoacetyltriglycine (MAG 3) scans. Gross and histological morphological changes were assessed at one and 30 days following application of PSW. Application of single clinical dose PSW was not associated with any significant functional or morphological renal injury. Excess dose PSW caused transient gross renal contusion, which resolved in the majority of animals with no persistent microscopic abnormality. Divided excess dose PSW resulted in no gross or microscopic damage. High frequency PSW was associated with mild histological abnormality. Multiple PSW treatments caused small discrete fibrotic lesions in all cases, without any change in renal function.
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Mechanical measures in the prophylaxis of postoperative thromboembolism in total knee arthroplasty. Total knee arthroplasty patients are at high risk for deep venous thrombosis and pulmonary embolism. Prophylaxis against deep venous thrombosis and pulmonary embolism in these patients seems mandatory. Pharmacologic agents such as dextran 40, aspirin, and warfarin are effective but may be associated with significant complications such as drug reaction, bleeding, hematoma, and hemarthrosis. Heparin was not effective and was associated with significant bleeding complications. Mechanical methods such as continuous passive motion and sequential pneumatic compression stockings were without complications and seemed equal to or more effective than pharmacologic agents. Adding warfarin to mechanical methods did not seem to augment the antithromboembolic effect of the mechanical methods.
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IgG1-mediated acute pulmonary hypersensitivity response in the guinea pig. Involvement of specific lipid mediators. We determined the pulmonary obstructive response to aerosolized antigen challenge, and its sensitivity to antagonists of specific lipid mediators, in IgG, passively sensitized (IgG1-PS) guinea pigs. Antiovalbumin (OA)-IgG1 was isolated by affinity chromatography from serum derived from actively immunized Hartley guinea pigs. Propranolol and pyrilamine pretreated, IgG1-PS guinea pigs were challenged with aerosolized antigen and pulmonary obstruction was quantified by measurements of excised lung gas volume (ELGV). ELGV increased between 150 and 1,035% in a dose-proportional fashion with increasing antigen exposure (0.001 to 0.1% nebulizer concentration). The leukotriene antagonists ICI-204,219 and SKF-104,353 exhibited dose-proportional inhibitions in antigen-induced elevations in ELGV, inhibiting up to 65 and 87% at the maximal concentrations examined. Similarly, the platelet-activating factor (PAF) antagonists WEB-2086 and L-659,989 inhibited antigen-induced elevations in ELGV, inhibiting up to 94 and 59% at the maximal concentrations examined. In contrast, the cyclooxygenase (CO) inhibitor piroxicam significantly enhanced (p less than 0.05) the OA-induced elevations in ELGV. Aerosolized PAF challenge produced dose-proportional elevations in ELGV that were significantly inhibited by the LTD, antagonist ICI-204,219 (38 and 43% inhibition) and the CO inhibitor piroxicam (62 and 48% inhibition) in sensitized and nonsensitized animals, respectively. We hypothesize that IgG1-dependent airway obstruction is mediated in part by LTD, produced in response to PAF generation.
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Recognition by ELAM-1 of the sialyl-Lex determinant on myeloid and tumor cells. Endothelial leukocyte adhesion molecule-1 (ELAM-1) is an endothelial cell adhesion molecule that allows myeloid cells to attach to the walls of blood vessels adjacent to sites of inflammation. ELAM-1 recognizes the sialyl-Lewis X (sialyl-Lex) determinant, NeuAc alpha 2-3Gal beta 1-4(Fuc alpha 1-3)GlcNAc-, a granulocyte carbohydrate also found on the surface of some tumor cell lines. Binding of myeloid cells to soluble ELAM-1 is inhibited by a monoclonal antibody recognizing sialyl-Lex or by proteins bearing sialyl-Lex, some of which may participate in humoral regulation of myeloid cell adhesion. Stimulated granulocytes also release an inhibitor of ELAM-1 binding that can be selectively adsorbed by monoclonal antibody to sialyl-Lex.
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Carcinoma of the pancreas: a retrospective review. Eighty-five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment. The most useful diagnostic test was percutaneous transhepatic cholangiography (PTC) with a diagnostic rate of 96%. Pancreaticoduodenectomy (Whipple procedure) and total pancreatic resection were performed in 13 and 2 patients, respectively. The remaining 50 patients underwent various palliative drainage procedures. Twenty patients did not undergo operation for various reasons. The primary tumor was found in the head of the pancreas in 50 patients (59%), the body in 6 patients (7%), and in the tail in 8 patients (9%). Postoperative complications, including sepsis, bleeding, intra-abdominal abscesses, and anastomotic leaks, occurred in 37% of the patients. There were one operative and 9 postoperative deaths. The average survival for those patients undergoing surgical intervention was 6 months. There were no 5-year survivors.
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A surgical approach to the cervicothoracic spine. We describe a method for approaching the lower cervical and upper thoracic spine, the brachial plexus and related vessels. The method involves the elevation of the medial corner of the manubrium, the sternoclavicular joint, and the medial half of the clavicle on a pedicle of the sternomastoid muscle. We have used this exposure in 17 cases with few complications and good results. Its successful performance requires high standards of anaesthesia, surgical technique and postoperative care.
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The painful shoulder: Part II. Intrinsic disorders and impingement syndrome. Intrinsic disorders that can cause shoulder pain include arthritis, gout, pseudogout and osteonecrosis. In its mildest form, impingement syndrome may cause only minimal discomfort. At its worst, impingement syndrome may lead to rotator cuff tear. Bicipital tendinitis and rupture of the biceps tendon may also be associated with impingement. Early rehabilitative intervention is important. Physical therapy is directed toward restoring range of motion and muscle strength.
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Alterations in brain phosphate metabolite concentrations in patients with human immunodeficiency virus infection. Human immunodeficiency virus (HIV)-infected individuals often demonstrate neuropsychiatric impairment; however, it is unclear how brain metabolism may be altered in such patients. We used in vivo phosphorus 31 magnetic resonance spectroscopy to noninvasively assess brain energy and phospholipid metabolism by measuring brain concentrations of adenosine triphosphate (ATP), phosphocreatine (PCr), and inorganic phosphate (Pi), as well as phospholipid compounds and intracellular pH. In study 1, 17 HIV-seropositive men with varying degrees of neuropsychiatric impairment and six control subjects were studied. Localized spectra were obtained from a heterogeneous 5 x 5 x 5-cm volume of interest (VOI). Patients with HIV infection had a significantly lower ATP/Pi ratio and a trend for a lower PCr/Pi ratio than did the control group. In addition, the ATP/Pi and PCr/Pi ratios were both significantly negatively correlated with overall severity of neuropsychiatric impairment. In study 2, three HIV-seropositive men with neuropsychiatric impairment were compared with 11 HIV-seronegative men. Localized phosphorus 31 magnetic resonance spectra were obtained from two relatively homogeneous VOIs: (1) a predominantly white matter VOI, and (2) a predominantly subcortical gray matter VOI. The three HIV-infected patients demonstrated significantly decreased ATP and PCr concentrations in the white matter VOI. These results suggest that HIV infection of the brain may impair brain cellular oxidative metabolism and that the degree of metabolic compromise may be related to the severity of neuropsychiatric impairment.
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Chiari pelvic osteotomy for osteoarthritis. The influence of the torn and detached acetabular labrum. We assessed the results of Chiari pelvic osteotomy in 64 hips with early osteoarthritis in terms of acetabular labral detachment detected pre-operatively by arthrography. At an average follow-up of four years, assessment by the Merle d'Aubigne score showed 83% excellent or good results. These satisfactory results were achieved in only half the cases with a detached labrum, but in nearly all cases with normal or torn acetabular labra. Other factors such as the acetabular index, the level and angle of osteotomy, and the displacement following osteotomy did not affect the results. Chiari pelvic osteotomy is a worthwhile procedure for early osteoarthritis in selected cases, but a detached acetabular labrum increases the risk of clinical failure.
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Clinicopathologic and flow cytometric DNA study of medullary thyroid carcinoma. Sixty-one patients with medullary thyroid carcinoma were investigated to establish relationships between the neoplasm's DNA content, other clinicopathologic factors, and patient survival (at least 5 years' follow-up). There were 26 (42.6%) familial and 35 (57.4%) sporadic carcinomas. Forty-two neoplasms (68.8%) were diploid and 19 (31.2%) were aneuploid by flow cytometric assessment. In univariate analysis, age, hereditary background, DNA content, calcitonin immunoreactivity, and type of surgery were strong predictors of clinical outcomes. In multivariate regression analysis, none of these factors was an independent prognosticator. Patients' gender, clinical stage, histologic subtype, and amyloid content of the tumor did not influence survival.
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Ventricular stroke work loss: validation of a method of quantifying the severity of aortic stenosis and derivation of an orifice formula Because aortic stenosis results in the loss of left ventricular stroke work (due to resistance to flow through the valve and turbulence in the aorta), the percentage of stroke work that is lost may reflect the severity of stenosis. This index can be calculated from pressure data alone. The relation between percent stroke work loss and anatomic aortic valve orifice area (measured by planimetry from videotape) was investigated in a pulsatile flow model. Thirteen valves were studied (nine human aortic valves obtained at necropsy and four bioprosthetic valves) at stroke volumes of 40 to 100 ml, giving 57 data points. Valve area ranged from 0.3 to 2.8 cm2 and mean systolic pressure gradient from 3 to 84 mm Hg. Percent stroke work loss, calculated as mean systolic pressure gradient divided by mean ventricular systolic pressure x 100%, ranged from 7 to 68%. It was closely related to anatomic orifice area with an inverse exponential relation and was not significantly related to flow (r = -0.15). An orifice formula was derived that predicted anatomic orifice area with a 95% confidence interval of +/- 0.5 cm2 (orifice area [cm2] = 4.82 [2.39 x log percent stroke work loss], r = -0.94, SEE = 0.029). These results support the clinical use of percent stroke work loss as an easily obtained index of the severity of aortic stenosis.
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Esophageal contribution to chest pain in patients with coronary artery disease. We conducted a prospective study to determine the role of the esophagus in causing chest pain in patients with established CAD on optimum therapy. Thirty-two men with documented CAD who complained of frequent and usually daily retrosternal chest pain were evaluated. Following a standard esophageal manometry and acid perfusion test, simultaneous two-channel ambulatory Holter monitor and esophageal pH record tests were performed for 24 hours. Fifty-three episodes of chest pain were documented in 20 patients; 11 patients were free of pain. Of the 20 patients who complained of chest pains, 17 (85 percent) demonstrated at least one episode of PPR, defined as a drop in distal esophageal pH to less than 4 within ten minutes before or after the onset chest pain. Episodes of asymptomatic GER were common. The correlation of PPR with chest pain was 70 percent (37/53 episodes) and of ischemic ECG changes with chest pain 13 percent (7/53); in the remaining, there was no correlation with either. Two patients demonstrated simultaneous PPR and ischemic ECG changes. Seventeen esophageal motility abnormalities were observed in 14 patients (45 percent). It is our conclusion that esophageal disorders contribute to chest pain in patients with documented CAD. In this group, GER plays a greater role than in those with normal coronary arteries. In addition, esophageal motility disorders are common in these patients. Esophageal testing can be undertaken safely in these patients.
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Superficial femoral artery as inflow for bypass to the proximal popliteal artery. We have obtained long term follow-up on 58 patients in whom the superficial femoral artery was used as a donor site for bypass to the proximal popliteal artery. The indication for the reconstructive procedure was intermittent claudication 36%, rest pain 34%, and gangrene 26%. All patients had angiographic evidence of a patent proximal superficial femoral artery and many had relative indications for short bypass such as limited saphenous vein availability or compromised medical condition. There was a cumulative patency rate of 79% by life table method for the series with a six year follow-up. We have observed that the superficial femoral artery is a satisfactory inflow site for proximal popliteal bypass grafts in selected patients. The procedure can maximize use of a limited segment of vein with minimal operative time and morbidity. Inflow stenosis can be revised or long bypass procedures can be offered in the event of graft failure.
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The "numb cheek-limp lower lid" syndrome. A patient developed isolated numbness, 1st confined to the lateral nose and upper lip, but later involving the cheek, lower lip, upper gingiva, and the palate. This numbness was later associated with paresis of the muscles of the upper lip and angle of the mouth and with ipsilateral lower lid droop (the "numb cheek-limp lower lid" syndrome). Squamous cell carcinoma was discovered infiltrating the infraorbital nerve and distal branches of the facial nerve. Cheek numbness associated with lower eyelid or upper lip weakness may herald a neoplasm affecting the infraorbital nerve and distal facial nerve branches.
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Molteno implants and operating microscope-induced retinal phototoxicity. A clinicopathologic report. The right eye of a 75-year-old man with a history of cataract extraction, three penetrating keratoplasties, laser trabeculoplasty, two Molteno implants, and an operating microscope-induced retinal phototoxic lesion was studied post mortem. Histopathologic examination of the anterior segment showed evidence of penetrating keratoplasty, cataract surgery, and two Molteno implants with minimal associated tissue response. Ultrastructural examination showed a loose collagenous matrix surrounding the Molteno reservoirs, suggesting aqueous percolation from the reservoirs into the conjunctiva. Posteriorly, in the area of the phototoxic operating microscope-induced lesion, a nodule of retinal pigment epithelial hyperplasia with overlying atrophy of the photoreceptor cell layer of the neurosensory retina was noted. The retina also contained cystoid macular edema and an extensive preretinal membrane that was clinically unexpected.
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Translocation (9;22) is associated with extremely poor prognosis in intensively treated children with acute lymphoblastic leukemia. The prognostic implications of t(9;22)(q34;q11) were assessed at a median follow-up of 3.5 years in 434 children receiving intensive treatment for acute lymphoblastic leukemia (ALL). Four-year event-free and overall survivals were 81% and 88%, respectively, in 419 children lacking t(9;22), but were 0% and 20%, respectively, in 15 children with t(9;22) (P less than .001). Poor outcome for children with t(9;22)-positive ALL was particularly notable because we have reported improved survival in other historically poor prognosis ALL cytogenetic categories when treated with similarly intensive therapy. We recommend that very intensive treatment approaches, including bone marrow transplantation in first remission, be considered for all children with t(9;22)-positive ALL.
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Cardioprotective effects of amlodipine on ischemia and reperfusion in two experimental models. The cardioprotective effect of amlodipine, a long-acting dihydropyridine derivative, was studied in 2 experimental models of ischemia and reperfusion. Isolated and blood-perfused feline hearts were made globally ischemic for 60 minutes and then reperfused for 60 minutes. Alterations of left ventricular developed pressure and compliance were monitored in both amlodipine-treated hearts and saline-treated control animals. Changes in perfusion pressure indicated that amlodipine significantly reduced myocardial oxygen consumption and coronary vascular resistance. Furthermore, a progressive increase in resting left ventricular diastolic pressure indicated that amlodipine, administered before the onset of global ischemia, attenuated the development of ischemic contracture. Return of contractile function 60 minutes after reperfusion and maintenance of tissue concentrations of electrolytes were significantly better in the amlodipine-treated group than in the control animals. In intact canine hearts, regional myocardial ischemia was induced for 90 minutes, followed by 6 hours of reperfusion. Although the hemodynamic variables and the size of the region of risk did not differ significantly between treated animals and control animals, the infarct size was significantly smaller in the amlodipine-treated group than in the control animals, and a gradual reduction in coronary blood flow was observed in the control group that was prevented in the amlodipine group. A comparison of these findings with those observed with oxygen radical scavengers also is discussed. A detailed report of these studies was published in The American Journal of Cardiology (1989;64:101I-116I). This review is included here to maintain continuity of the symposium for the convenience of the reader.
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Prospective study of the frequency and size distribution of polyps missed by colonoscopy. An important determinant in interpreting the results of colorectal polyp chemoprevention trials is the rate of polyps missed during colonscopic examination. We prospectively examined 90 patients by tandem colonoscopy performed by two alternating examiners. In 69 (76.7%) patients, 221 neoplastic lesions were documented histologically. Of a total of 58 lesions detected in 31 patients, no neoplastic lesion greater than or equal to 10 mm in size was missed; 16% of diminutive (less than or equal to 5 mm) neoplastic polyps and 12.3% of medium-sized (6-9 mm) neoplastic polyps were missed by the first examiner. We conclude that an experienced colonoscopist will miss about 15% of colorectal neoplastic polyps less than 10 mm in size in the setting of adequate bowel preparation. Large (greater than or equal to 10 mm) polyps were rarely missed, however, with the "miss" rate in our study equal to 0, with a 95% confidence limit of 4.64%.
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Intravenous fluid load and recovery. A double-blind comparison in gynaecological patients who had day-case laparoscopy. The effect of intra-operative fluid and dextrose administration upon recovery was tested in a randomised, double-blind trial. Three groups of 25 patients, each undergoing laparoscopic examination as day cases, were studied. The two groups who received fluid (20 ml/kg compound sodium lactate solution) showed significant improvement (p less than 0.05) in the variables that reflected hydration. The fluid group who also received dextrose (1 g/kg) exhibited further significant improvement. Intra-operative fluid and dextrose administration appears to confer some benefit upon recovery in patients who have minor surgery.
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Post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. Is it necessary to resect all residual masses? A total of 15 patients with advanced nonseminomatous testicular cancer underwent 2 sequential operations (4 in 1 patient) to remove residual masses after cisplatin-based combination chemotherapy. All patients had normal human chorionic gonadotropin and alpha-fetoprotein levels but persistent radiographic masses after chemotherapy. The operations included retroperitoneal lymph node dissection in 13 patients, thoracotomy in 15, hepatic resection in 3 and craniotomy in 1. Histological comparison of the specimens resected during post-chemotherapy operations 1 and 2 demonstrated different patterns in 7 of 15 patients. Of these 7 patients 4 had less favorable pathological features in the specimen removed during the second procedure. Residual malignant tumor or mature teratoma was found in at least 1 site in 12 of the 15 patients and only 3 had complete necrosis or fibrosis in both specimens examined. These data indicate the favorable impact of excising all post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. However, in patients with no teratomatous elements in the testicular tumor and complete necrosis or fibrosis in the initial post-chemotherapy operation specimen the probability of complete necrosis or fibrosis in remaining tumors appears to be high.
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Cation-dependent mannose 6-phosphate receptor contains two internalization signals in its cytoplasmic domain [published erratum appears in Proc Natl Acad Sci U S A 1991 Feb 15;88(4):1591] The signals required for rapid internalization of the bovine cation-dependent mannose 6-phosphate receptor have been localized to two distinct regions of the 67-amino acid cytoplasmic domain. One signal includes phenylalanine 13 and phenylalanine 18, while the other involves tyrosine 45. The former signal is more potent than the latter, but both must be present for the maximal rate of receptor internalization. Each signal shares similarities with the known internalization signals of other recycling receptors.
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Reoperative surgery for the morbidly obese. A university experience. Patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications. To evaluate outcome following revisional procedures, we reviewed the records of 32 such patients treated at UCLA between April 1986 and May 1989. Twenty-five women (78%) and 7 men (22%) with a mean age of 44 years underwent 76 reoperations (2.4 per patient) for complications of prior obesity surgery. Indications for initial surgical revision consisted primarily of metabolic derangements (12 patients) and weight-related problems (11 patients). In contrast, indications for the patients' final surgical procedure were commonly for bowel obstruction (41%), intra-abdominal sepsis (12%), and gastrointestinal bleeding (6%). Following initial revision, 23 patients (71.8%) required further surgery for major complications and four patients died (12.5%). While initial revisions are frequently indicated for metabolic problems, final reoperations are more frequently undertaken for urgent, life-threatening complications. Revisional procedures for morbid obesity should be carefully considered, and the potential for major complications and/or death should be weighted heavily against proposed benefits.
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A controlled trial of community based coronary rehabilitation. Two hundred patients who had suffered an acute myocardial infarction 4-6 weeks before entered a randomised controlled trial of exercise treatment at a community sports centre supervised by a general practitioner. Eighty one per cent of the treatment group continued to exercise until they returned to work and 73% completed three months' exercise. There were no serious complications of the exercise course. The prevalence of angina pectoris fell by 10% in the treatment group but rose by 60% in the control group. The perceived energy level rose by significantly more in the treatment group than in the controls. The rise in predicted maximum oxygen uptake was significantly greater in the treatment group than in the control group as was the reduction in the double product (a reflection of myocardial workload) at peak exercise. Coronary rehabilitation in the community can be both safe and effective.
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Lung beta-adrenoceptors in pulmonary hypertension. A study of biopsy specimens in children with congenital heart disease. Characteristics of beta-adrenoceptors were analyzed using radioligand-binding techniques with 3H-dihydroalprenolol in lung specimens from 11 children with pulmonary hypertension (median age, three years) undergoing surgical repair of congenital heart defects and four pediatric control subjects (median age, five years) undergoing thoracotomy for removal of neoplasms or cysts. Scatchard analysis of 3H-DHA binding to lung membranes showed similar values of the dissociation constant in both groups (Kd = 0.72 +/- 0.22 nM in patients vs 1.22 +/- 0.22 nM in controls; p = NS). The receptor density was significantly increased in patients in comparison with controls, with respective values of 164 +/- 19 and 95 +/- 13 fmol/mg of protein (p less than 0.025), and correlated directly with mean pulmonary arterial pressure (r = 0.82; p less than 0.0005). No significant relationship was observed between receptor number and pulmonary arterial medial thickness. Thus, the increase in receptor density in these patients may be related to adaptative changes in cells other than vascular smooth muscle.
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Multiple arterial fenestrations, multiple aneurysms, and an arteriovenous malformation in a patient with subarachnoid hemorrhage. We report the case of a 49-year-old, right-handed man with multiple vascular pathologies, including a fenestrated anterior communicating artery and middle cerebral artery, an aneurysm of the anterior communicating artery, multiple aneurysms of the middle cerebral artery, and an arteriovenous malformation. Diagnoses were made through computed tomography, cerebral angiography, magnetic resonance imaging, and intraoperative dissection. The lesions were managed surgically in stages with satisfactory results. Congenital and hemodynamic factors may have combined to manifest in the anomalies present in this unique case. We believe that no similar combination of vascular pathology has been reported previously.
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Stroke recurrence within 2 years after ischemic infarction. We prospectively studied stroke recurrence in 1,273 patients with ischemic stroke who were entered into the Stroke Data Bank. Median follow-up was 13 months. The 2-year cumulative recurrence rate among these patients was 14.1%. Age, sex, race, history of hypertension, atrial fibrillation, or transient ischemic attacks, and stroke location were not associated with a higher risk of stroke recurrence. Patients with an elevated blood pressure, an abnormal initial computed tomogram, or a history of diabetes mellitus were at a higher risk of stroke recurrence. In contrast, patients with an infarct of unknown cause were at a lower risk of stroke recurrence than patients with a defined stroke mechanism, such as lacune, embolism, or atherosclerosis. A multivariate model suggests that patients at the lowest risk for stroke recurrence have a low diastolic blood pressure, no history of stroke, no history of diabetes mellitus, and an infarct of unknown cause.
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Sodium-potassium interaction in hypertension and hypertensive cardiovascular disease. Epidemiological evidence suggests that low potassium intake is associated with the probability of occurrence of hypertension and stroke. The short-term response to increased potassium intake is increased sodium excretion as well as increased potassium excretion; the short-term response to increased sodium intake is increased potassium excretion as well as increased sodium excretion. In some experimental studies, increased amounts of potassium have been able to block the noxious influences of sodium. Sodium and potassium must be concomitantly considered in the investigation of the association of either of these cations with hypertension and cardiovascular disease. The chloride ion is also important for sodium's effects; its importance in potassium's effects has not been extensively explored.
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Relationship between histologic features, DNA flow cytometry, and clinical behavior of squamous cell carcinomas of the larynx. Flow cytometric analysis of DNA content was done on 133 primary squamous cell carcinomas of the larynx. Overall, 76 tumors (57.1%) were not diploid (aneuploid or tetraploid). The DNA index (DI) was calculated and grouped into three levels. Fifty-seven cases had a DI in a range of 1.85 to 2.15 (44 diploid and 13 tetraploid). The cases were grouped in relation to ploidy, proliferative index, and the tumor-node-metastasis (TNM) system. Every group was analyzed with respect to survival rate. Ploidy was related to histocytologic grade. In well-differentiated tumors (G1) survival rates at 48 months were 41.7% in diploid cases and 27.7% in nondiploid ones (relative risk [RR], 2.01; 95% confidence interval [CI], 0.89, 4.52). In NO cases that underwent surgery, survival rates at 48 months were, respectively, 81.8% and 49.2% (RR, 5.07; 95% CI, 0.76, 33.93). These results suggest that ploidy may be a new independent parameter of prognosis in squamous cell carcinoma of the larynx. This is useful in clinical practice because it allows the clinician to recognize those cases with poorer prognosis among the early tumors at a stage where other prognostic parameters are not yet available.
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Modified Van Nes rotationplasty for osteosarcoma of the proximal tibia in children Above-knee amputation has been the traditional treatment for osteosarcoma of the proximal tibia. Recent advances in chemotherapy have encouraged the development of limb-salvage techniques. Van Nes rotationplasty for malignant lesions of the distal femur has increased in popularity as a reconstructive technique, but no similar procedure has been described for lesions of the proximal tibia. We have developed a modified rotationplasty for this lesion and have performed it in four children. The surgical technique, postoperative management and results of the procedure are described. Two patients had delayed wound healing. No other complications have developed and our patients were disease-free at follow-up, while the appearance of the leg was well accepted by the patients and their parents. This procedure is a useful addition to the armamentarium of the tumour surgeon for the treatment of malignant lesions of the proximal tibia.
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Effects of low perfusate Ca2+ concentration on newborn myocardial function after ischemia. A greater dependence on transsarcolemmal Ca2+ flux and immaturity of Ca2+ sequestration capacity may potentiate Ca2(+)-mediated reperfusion injury in the newborn myocardium. The effect of serum ionized Ca2+ concentration on left ventricular systolic and diastolic function after ischemia was studied in 5-7-day-old piglets undergoing a 90-minute period of cold-blood cardioplegic arrest. In the control group, Ca2+ was maintained at 1.2 mM (Group A [n = 6]). The cardioplegic solution and bypass perfusate were modified to achieve a low Ca2+ concentration, 0.25 mM, in Group B (n = 6). Left ventricular pressure-volume loops were acquired by using high-fidelity pressure-sensor-tipped and volume-conductance catheters. Ventricular function was assessed from the slope of end-systolic (Ees) and end-diastolic (k) pressure-volume relations during transient caval occlusion. Both groups showed a significant reduction in Ees after ischemia (p less than 0.05). Intergroup comparison of Ees after ischemia demonstrated a better recovery of the systolic function in the low Ca2+ group, 64 +/- 7% versus 49 +/- 6% in the normal Ca2+ group (p = 0.05). There was a significant increase in chamber stiffness index in group A (k, 0.48 +/- 0.06 to 0.65 +/- 0.05 ml-1, p less than 0.01) versus no significant change in group B. This study shows 1) the feasibility of acquiring continuous pressure-volume data in neonatal hearts by using a conductance catheter system, and 2) better preservation of systolic function and diastolic compliance in normal newborn myocardium by low Ca2+ concentration in the peri-ischemic period.
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Urovirulence determinants in Escherichia coli isolates causing first-episode and recurrent cystitis in women. To assess the prevalence of urovirulence determinants among Escherichia coli isolates from women with acute uncomplicated cystitis, 121 isolates from 87 women with first-episode or recurrent cystitis and 156 fecal isolates from 52 women without recent urinary tract infection were tested using DNA probes for P fimbriae, hemolysin, aerobactin, and diffuse adhesin and for expression of hemolysin and P and F adhesins. P fimbrial genotype (P = .002), hemolysin phenotype (P = .007), and the diffuse adhesin determinant (P = .03), but not aerobactin, were found more frequently in E. coli from women with acute cystitis, and expression of the F adhesin (41%) was more common than the P adhesin (24%; P = .001). E. coli isolates that caused cystitis in women using diaphragms had fewer virulence determinants than those from nonusers (P = .04), suggesting that diaphragm use may allow infection with less virulent E. coli.
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Diagnosis of Lyme disease based on dermatologic manifestations. Lyme disease, or Lyme borreliosis, is an infection caused by the spirochete Borrelia burgdorferi, which is most commonly transmitted to humans by a tick bite. Characterized by early and late phases, Lyme disease is a multisystem illness involving the skin, heart, joints, and nervous system. Diagnosis is based predominantly on clinical manifestations, the most specific being dermatologic. Thus, recognizing the dermatologic manifestations of Lyme disease is important for diagnosis and institution of appropriate, effective therapy. Approximately 75% of patients with Lyme disease present with the pathognomonic skin lesion erythema migrans, an expanding erythematous lesion. During early infection, secondary erythema migrans lesions or Borrelia lymphocytoma may occur. Borrelia lymphocytoma commonly presents as an erythematous nodule on the ear lobe or nipple. During late infection, acrodermatitis chronica atrophicans, an erythematous, atrophic plaque unique to Lyme disease may appear; it has been described in about 10% of patients with Lyme disease in Europe. Fibrotic nodules associated with acrodermatitis chronica atrophicans as well as other sclerotic and atrophic lesions, such as morphea, lichen sclerosus et atrophicus, anetoderma, and atrophoderma of Pasini and Pierini, have been seen late in the course of Lyme disease. In a few cases, other sclerodermatous lesions, such as eosinophilic fasciitis and progressive facial hemiatrophy, have been linked to B. burgdorferi infection. We review the cutaneous lesions associated with Lyme disease.
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Passive smoking and heart disease. Epidemiology, physiology, and biochemistry. The evidence that ETS increases risk of death from heart disease is similar to that which existed in 1986 when the US Surgeon General concluded that ETS caused lung cancer in healthy nonsmokers. There are 10 epidemiological studies, conducted in a variety of locations, that reflect about a 30% increase in risk of death from ischemic heart disease or myocardial infarction among nonsmokers living with smokers. The larger studies also demonstrate a significant dose-response effect, with greater exposure to ETS associated with greater risk of death from heart disease. These epidemiological studies are complemented by a variety of physiological and biochemical data that show that ETS adversely affects platelet function and damages arterial endothelium in a way that increases the risk of heart disease. Moreover, ETS, in realistic exposures, also exerts significant adverse effects on exercise capability of both healthy people and those with heart disease by reducing the body's ability to deliver and utilize oxygen. In animal experiments, ETS also depresses cellular respiration at the level of mitochondria. The polycyclic aromatic hydrocarbons in ETS also accelerate, and may initiate, the development of atherosclerotic plaque. Of note, the cardiovascular effects of ETS appear to be different in nonsmokers and smokers. Nonsmokers appear to be more sensitive to ETS than do smokers, perhaps because some of the affected physiological systems are sensitive to low doses of the compounds in ETS, then saturate, and also perhaps because of physiological adaptions smokers undergo as a result of long-term exposure to the toxins in cigarette smoke. In any event, these findings indicate that, for cardiovascular disease, it is incorrect to compute "cigarette equivalents" for passive exposure to ETS and then to extrapolate the effects of this exposure on nonsmokers from the effects of direct smoking on smokers. These results suggest that heart disease is an important consequence of exposure to ETS. The combination of epidemiological studies with demonstration of physiological changes with exposure to ETS, together with biochemical evidence that elements of ETS have significant adverse effects on the cardiovascular system, leads to the conclusion that ETS causes heart disease. This increase in risk translates into about 10 times as many deaths from ETS-induced heart disease as lung cancer; these deaths contribute greatly to the estimated 53,000 deaths annually from passive smoking. This toll makes passive smoking the third leading preventable cause of death in the United States today, behind active smoking and alcohol.
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Case-control study of coronary heart disease risk factors in the elderly. We undertook a case-control study utilizing a large coronary arteriography database to determine if traditional cardiovascular risk factors are as predictive of the presence of angiographically-proven coronary artery disease (CAD) in elderly patients as in younger patients. Among the patients aged 65 years or more, there were 2120 cases and 193 controls, while for the patients aged 35-49 years there were 1493 cases and 707 controls. Odds ratios obtained from logistic regression indicated that age, male sex, diabetes, cigarette smoking, hypertension, total cholesterol and left ventricular hypertrophy were all significant risk factors for CAD in both age groups, although the odds ratios tended to be somewhat lower in the elderly. Logistic regression analysis for gender subgroups generally revealed similar findings when compared with the combined (males + females) age groups, although power was limited for the subgroup of elderly males which had few controls. We conclude that most of the traditional cardiovascular risk factors which have been described as correlated with the presence of CAD in younger populations are also correlated with angiographically-proven CAD in older patients.
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Characterization of an interleukin-6-mediated autocrine growth loop in the human multiple myeloma cell line, U266. It has been reported recently that freshly isolated human myeloma cell cultures proliferate in response to added interleukin-6 (IL-6). Endogenous levels of IL-6 found in the same cultures suggested that an autocrine growth loop may contribute to cell growth. However, the lack of homogenous cell populations in primary myeloma cultures has made it difficult to distinguish between paracrine and autocrine growth mechanisms. To precisely address the autocrine growth issue we have evaluated the growth of the human myeloma cell line, U266. We have found that a neutralizing anti-IL-6 monoclonal antibody can inhibit U266 proliferation. Furthermore, the addition of IL-6 antisense oligonucleotides also inhibits U266 proliferation. These effects are reversed by adding IL-6, suggesting the presence of an autocrine loop. Using bioassays with two different IL-6-dependent cell lines, we were able to detect IL-6 in concentrated U266 supernatants. IL-6 mRNA was detected by polymerase chain reaction amplification of cDNA. Cell cycle parameter analysis shows that IL-6 acts to release a block in G1. Taken together these results present conclusive evidence for IL-6-mediated autocrine growth in the U266 human myeloma cell line.
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Characteristics of black patients admitted to coronary care units in metropolitan Seattle: results from the Myocardial Infarction Triage and Intervention Registry (MITI). Since 1988, 641 black and 11,892 white patients with chest pain of presumed cardiac origin have been admitted to coronary care units in 19 hospitals in metropolitan Seattle. Black men and women were younger (58 vs 66, p less than 0.0001), more often admitted to central city hospitals (p less than 0.0001), and developed evidence of acute myocardial infarction (AMI) less often (19 vs 23%, p = 0.01). In the subset of 2,870 AMI patients, blacks (n = 121) were younger (59 vs 67, p less than 0.0001) and had less prior coronary artery bypass graft surgery (2 vs 10%, p = 0.005) and more prior hypertension (67 vs 46%, p less than 0.0001). During hospitalization, whites (n = 2,749) had higher rates of coronary angioplasty (18 vs 10%, p = 0.03) and coronary artery bypass graft surgery (10 vs 4%, p = 0.04), although thrombolytic therapy and cardiac catheterization were used equally in the 2 groups. Hospital mortality was 7.4% for black and 13.1% for white patients (p = 0.07). However, after adjustment for key demographic and clinical variables by logistic regression, this difference was not as apparent (p = 0.38). Questions about the premature onset of coronary artery disease, excess systemic hypertension, and the differential use of interventions in black persons have been raised by other investigators. Despite differences in age, referral patterns and the use of coronary angioplasty and bypass surgery, black and white patients with AMI in metropolitan Seattle had similar outcomes.
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Ichthyosis, exocrine pancreatic insufficiency, impaired neutrophil chemotaxis, growth retardation, and metaphyseal dysplasia (Shwachman syndrome). Report of a case with extensive skin lesions (clinical, histological, and ultrastructural findings). The Shwachman syndrome comprises exocrine pancreatic insufficiency, growth retardation, and bone marrow hypoplasia resulting in neutropenia. Clinical, morphological, and ultrastructural studies, as well as hair analysis, were performed in a patient with Shwachman's syndrome and severe ichthyosis. Clinical findings were lamellar ichthyosiform desquamation on the extremities. The hair was scanty and short on the scalp, in the eyelashes, and in the eyebrows. The nails were hyperkeratotic. Morphologic findings were slight, regular acanthosis and severe diffuse hyperkeratosis with variable parakeratosis. The granular layer was thickened. The papillary dermis showed very slight perivascular lymphocyte infiltration. The most prominent ultrastructural finding was the presence of solitary or multiple droplets of varying size in the cytoplasm of the keratinocytes. Hair analysis revealed no abnormalities; the cystine concentration in hair specimens was normal.
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Endometriosis of the abdominal wall. Endometriosis of the abdominal wall typically occurs as a painful mass in a lower abdominal incision from previous cesarean section or hysterectomy. Most patients are young and in their active reproductive years. The histologic diagnosis requires a combination of either endometrial-like glands, endometrial stroma, or hemosiderin pigment. The diagnosis must be considered in any woman with an abdominal wall mass and a history of transabdominal gynecologic surgery. Wide excision offers the best chance to prevent recurrence.
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Orthopedic complications. Compartment syndrome, fat embolism syndrome, and venous thromboembolism. Specialized education in the care of orthopedic patients includes an understanding of the common complications for which patients require monitoring. With a socioeconomic backdrop of decreasing hospital stays and prospective payment, patient care must be managed proactively. For all three complications presented, there are unique sets of risk factors that, when present, contribute to a high index of suspicion for morbidity. Clusters of symptoms have also been discussed representing the expected normal patterns. With this knowledge as a foundation, clinical application is essential to incorporate other salient aspects of individual situations. Nurses diagnose and treat human responses to health problems. The end result of human responses to injury or orthopedic conditions can be the development of complications. Stringent adherence to patient monitoring protocols can promote timely nursing interventions to prevent, minimize, or detect complications or treatment side effects. Although definitive treatment is often physician directed, nurses are in a key role to impact final patient outcomes.
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Effect of hydrocephalus on prostaglandins and thromboxane B2 in ventricular cerebrospinal fluid. The concentrations of prostaglandin F2 alpha, prostaglandin E2, 6-ketoprostaglandin F1 alpha (prostacyclin metabolite), and thromboxane B2 were assayed in ventricular cerebrospinal fluid obtained from 28 patients with hydrocephalus (17 obstructive, 11 communicating). Seven patients received dexamethasone or hydrocortisone on the day of sampling. No patient received nonsteroidal anti-inflammatory compounds for 48 hours before sampling. The median values did not differ significantly between the two types of hydrocephalus or from the concentrations in lumbar cerebrospinal fluid obtained from patients without intracranial pathology during lumbar myelography for possible lumbar disc disease. Hence, there is no evidence that eicosanoids accumulate in the ventricles in hydrocephalus, and it is unlikely that they have a significant role in its symptomatology.
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Advantages of beta blockers versus antiarrhythmic agents and calcium antagonists in secondary prevention after myocardial infarction. Patients who have sustained greater than or equal to 1 myocardial infarcts are at high risk for sudden death or reinfarction; the risk is highest for those with lowest ventricular ejection fraction, continuing myocardial ischemia and asymptomatic high-density and complex premature ventricular contractions. At present, beta blockers when given prophylactically are the only agents that reduce the incidence of sudden death and reinfarction in survivors of myocardial infarction (MI) in the first 2 years. The beneficial effect was shown to correlate with a reduction in heart rate, the effect being absent or deleterious with beta blockers with marked sympathomimetic activity. The effects of beta blockers on ventricular fibrillation appeared to be dissociated from those on premature ventricular contractions. Trials with calcium antagonists indicate that these drugs had no effect or increased the mortality rate. The divergent effect of beta blockers and calcium antagonists is unexplained but may be due in part to a lack of bradycardiac effect of calcium antagonists; there were no differences in effect among different calcium antagonists. Data from trials involving class I antiarrhythmic agents indicate that agents acting by depression of cardiac conduction are either devoid of effect or produce a modest increase in mortality. Results of the Cardiac Arrhythmia Suppression Trial, employing the newer class I agents flecainide and encainide, were used to determine whether the suppression of premature ventricular contractions in the survivors of acute MI reduces mortality. Flecainide and encainide suppressed premature ventricular contractions greater than 80%, but resulted in an increased mortality rate undoubtedly due to a marked proarrhythmic effect. Whether these data can be extrapolated to all class I agents is uncertain. Preliminary data with class III antiarrhythmic agents suggest that these agents, especially amiodarone, similarly to beta blockers, have the potential to reduce mortality in survivors of MI. Evolving data suggest that in the secondary prevention of morbid events in the survivors of acute MI, the focus must shift away from antiarrhythmic agents that delay conduction and toward beta blockers and antifibrillatory actions resulting from a prolongation of refractoriness.
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The effect of epilepsy or diabetes mellitus on the risk of automobile accidents BACKGROUND. Previous studies of possible associations between chronic medical conditions and traffic safety have been inconsistent and subject to bias because of the incomplete identification of affected persons. Recent advances in the diagnosis and management of epilepsy and diabetes mellitus have improved the control of these disorders and suggest a need to reexamine the risk of traffic mishaps among patients with these conditions. METHODS. We conducted a population-based retrospective cohort study of 30,420 subjects 16 to 90 years of age, with and without epilepsy or diabetes mellitus. Subjects included all the licensed drivers in seven contiguous ZIP Code areas in which the Marshfield Clinic and St. Joseph's Hospital, Marshfield, Wisconsin, are the primary sources of medical care. Standardized rates of moving violations and accidents over a four-year period (1985 through 1988) were compared in affected and unaffected cohorts. RESULTS. Standardized mishap ratios for subjects with diabetes were 1.14 for all moving violations (P = 0.23) and 1.32 for accidents (P = 0.01); for subjects with epilepsy the ratios were 1.13 for moving violations (P = 0.26) and 1.33 for accidents (P = 0.04). CONCLUSIONS. We conclude that drivers with epilepsy or diabetes mellitus have slightly increased risks of traffic accidents as compared with unaffected persons. The increases in risk observed in our study were generally smaller than those in previous studies, and we believe they are not great enough to warrant further restrictions on driving privileges.
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Renal transplant pyelocaliectasis: role of duplex Doppler US in evaluation. To distinguish the obstructed from the nonobstructed dilated collecting system of transplanted kidneys without interventional diagnostic measures, the authors prospectively evaluated duplex Doppler analysis (determination of resistive index [RI]) in 35 renal transplant patients with pyelocaliectasis. Proof of the presence or absence of obstruction was obtained at interventional procedures in 18 patients and at clinical follow-up in 17. Thirteen kidneys were obstructed (mean RI, .81 +/- .06), while 22 had nonobstructive dilatation (mean RI, .66 +/- .07). The RI difference was statistically significant (P less than or equal to .01). Of 21 kidneys with a normal RI, only two had obstruction. In both of these, the obstruction was associated with a significant peritransplant collection of fluid due to a ureteral leak. In the seven obstructed transplanted kidneys with follow-up, the mean RI was .82 +/- .06 before nephrostomy and .67 +/- .05 after nephrostomy. Obstruction was a common cause of an elevated RI (greater than or equal to .75). Other causes of transplant dysfunction can be associated with an elevated RI and nonobstructed dilatation. More important, a normal RI should strongly argue against obstruction unless a ureteral leak is also present.
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Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography. A statement by a Task Force Committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. Sufficient data are available to recommend the use of the high-resolution or signal-averaged electrocardiogram in patients recovering from myocardial infarction without bundle branch block to help determine their risk for developing sustained ventricular tachyarrhythmias. However, no data are available about the extent to which pharmacological or nonpharmacological interventions in patients with late potentials have an impact on the incidence of sudden cardiac death. Therefore, controlled, prospective studies are required before this issue can be resolved. As refinements in techniques evolve, it is anticipated that the clinical value of high-resolution or signal-averaged electrocardiography will continue to increase.
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Experimental models of temporal lobe epilepsy: new insights from the study of kindling and synaptic reorganization. Temporal lobe epilepsy is a common localization-related epileptic syndrome characterized by complex partial seizures, ictal and interictal epileptic discharges arising from limbic structures of the temporal lobe, and association with hippocampal sclerosis. Temporal lobe epilepsy may follow perinatal injury and febrile convulsions, may be progressive, and frequently becomes refractory to standard antiepileptic therapy. The neurobiology that underlies these features of temporal lobe epilepsy is not known. Recent studies in experimental models have provided new insights that may help clarify the relationship of seizures, hippocampal sclerosis, and temporal lobe epilepsy. Observations from the study of the hippocampus with kainic acid-induced lesions, the kindling model, and other experimental models of epilepsy have demonstrated that seizures induce structural and electrophysiologic alterations in hippocampal pathways that may lead to increased excitability and could play a role in the development and progression of temporal lobe epilepsy. These alterations include mossy fiber synaptic reorganization, induction of NMDA-mediated synaptic transmission, and progressive hippocampal neuronal loss induced by brief kindled seizures. Some of the structural alterations induced by kindling have also been observed in the human epileptic temporal lobe, raising the possibility that mechanisms operative in kindling may play a role in the pathogenesis of hippocampal sclerosis and in the syndrome of human temporal lobe epilepsy.
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Evidence of a local immune activation in cystic brain tumors. The fluid of cystic brain tumors was characterized with regard to the protein content. In most malignant tumors, the concentrations of immunoglobulins G and M (IgG and IgM) were higher relative to other proteins in the cyst fluid than in the serum of the same patient. A markedly elevated ratio of monomeric to pentameric IgM was detected in the cyst fluid of two patients with glioblastomas. The results indicate a local immunoglobulin synthesis in malignant cystic brain tumors. It is hypothesized that higher-than-expected concentrations of IgG and IgM in cyst fluid as compared to plasma are a sign of an ongoing immune response triggered by the tumor.
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Gender differences in age effect on brain atrophy measured by magnetic resonance imaging. A prospective sample of 69 healthy adults, age range 18-80 years, was studied with magnetic resonance imaging scans (T2 weighted, 5 mm thick) of the entire cranium. Volumes were obtained by a segmentation algorithm that uses proton density and T2 pixel values to correct field inhomogeneities ("shading"). Average (+/- SD) brain volume, excluding cerebellum, was 1090.91 ml (+/- 114.30; range, 822.19-1363.66), and cerebrospinal fluid (CSF) volume was 127.91 ml (+/- 57.62; range, 34.00-297.02). Brain volume was higher (by 5 ml) in the right hemisphere (P less than 0.0001). Men (n = 34) had 91 ml higher brain and 20 ml higher CSF volume than women (n = 35). Age was negatively correlated with brain volume [r(67) = -0.32, P less than 0.01] and positively correlated with CSF volume (r = 0.74, P less than 0.0001). The slope of the regression line with age for CSF was steeper for men than women (P = 0.03). This difference in slopes was significant for sulcal (P less than 0.0001), but not ventricular, CSF. The greatest amount of atrophy in elderly men was in the left hemisphere, whereas in women age effects were symmetric. The findings may point to neuroanatomic substrates of hemispheric specialization and gender differences in age-related changes in brain function. They suggest that women are less vulnerable to age-related changes in mental abilities, whereas men are particularly susceptible to aging effects on left hemispheric functions.
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Multimodal therapy in locally advanced breast carcinoma. Among 879 patients treated for breast cancer between 1975 and 1984, advanced disease was found in 125 (14%). A subgroup of 34 (4%) presented with untreated locally advanced disease without demonstrable distant metastases at the time of diagnosis (stage IIIB = T4abed, NX-2,MO). During the first 5 years (1975 through 1979), 17 patients were treated primarily with sequential radiotherapy and chemotherapy (Group A). From 1980 to 1984 (Group B), the management consisted of four courses of induction multi-drug chemotherapy followed primarily by mastectomy and additional chemotherapy. The mean follow-up for the most recent group (Group B) is 48 months. Follow-up was complete. While the local disease control rate was the same for both groups (76%), the survival was remarkably different. Group A patients experienced a median survival of 15 months, and only one survived 5 years. In Group B, the median survival was 56 months with nine patients (53%) alive between 40 and 76 months, seven (41%) of whom are 5-year survivors. While the overall mortality of patients with inflammatory breast cancer was greater in both groups when compared with the group with noninflammatory disease, the survival of patients in Group B was better than in Group A for both inflammatory and noninflammatory cancers (p less than 0.01). Estrogen receptor, nodal, and menopausal status did not influence survival. These data suggest that neoadjuvant chemotherapy improves survival for patients with stage IIIB breast carcinoma and delays the establishment or progression of distant metastases. Mastectomy is an important component in the treatment of this disease.
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Pathophysiology, monitoring, and management of the ventilator-dependent patient: considerations for drug therapy, emphasis on stress ulcer prophylaxis. Adult respiratory distress syndrome (ARDS), or noncardiac pulmonary edema, is a form of acute hypoxemic respiratory failure. The goals of treatment for patients with ARDS are to provide supportive therapy, to reverse the underlying etiology or pathology, and to prevent subsequent complications. Supportive therapy consists of supplemental oxygen, positive end-expiratory pressure, and, often, mechanical ventilation. The reversal of the underlying pathology varies according to the etiologic origin of ARDS. Complications from ARDS include stress ulcers, which occur when gastric aggressive and defensive functions become unbalanced. Antacids and cytoprotective agents are used for stress ulcer prophylaxis, but histamine H2-receptor antagonists are now regarded as the standard of care. Because all the marketed H2-receptor antagonists are efficacious, choice of the agent is based on the adverse effect profile and drug interactions. No definitive data currently exist linking stress ulcer prophylaxis regimens that raise intragastric pH to a significant risk for nosocomial pneumonia.
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Dissecting aneurysm of the pulmonary artery with pulmonary hypertension. Pulmonary artery dissection was observed in a 64-yr-old female patient with severe pulmonary hypertension, which was probably primary (pulmonary vascular resistance, 817 dyn.s.cm-5; normal range less than or equal to 200 dyn.s.cm-5). The patient was admitted to the hospital because of severe dyspnea on exertion. Echocardiography demonstrated a dissecting aneurysm of the pulmonary artery. Right heart catheterization revealed severe pulmonary hypertension (mean pulmonary artery pressure, 64 mm Hg; normal range, 10 to 22 mm Hg); dissection of the pulmonary artery was confirmed by pulmonary arteriography. One-year follow-up was uneventful. In the literature, 28 patients with dissecting aneurysm of the pulmonary artery are reviewed. The dissection has only been diagnosed in life in one patient (by echocardiography).
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Ulcerative proctitis in central Sweden 1965-1983. A population-based epidemiological study. Ulcerative proctitis has by tradition been regarded as a subgroup of ulcerative colitis. Population-based epidemiological studies of ulcerative proctitis are, however, virtually nonexistent. In an epidemiological study of inflammatory bowel disease in the Uppsala Health Care Region, 1065 cases of ulcerative proctitis were diagnosed from 1965 through 1983. Males predominated, with the male to female ratio 1.4:1. Annual incidence rates were higher in urban than in rural areas. The annual incidence rates increased threefold from 2.8 per 10(5) to 6.6 per 10(5) during the period, affecting all age groups over 14 years of age, in both urban and rural areas and in both sexes. Differences in temporal trends and certain other epidemiological characteristics between ulcerative proctitis and extensive ulcerative colitis suggest that ulcerative proctitis is a specific disease whose etiology differs from that of extensive ulcerative colitis.
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Imaging the gallbladder: a historical perspective. After Wilhelm Conrad Roentgen's discovery of the X-ray in 1895, it was initially thought that gallstones could not be visualized. Surgeons relied solely on the clinical examination to detect biliary disease. Today, no evaluation of the gallbladder would be complete without the performance of an imaging study. Radiology has gone through several eras in the imaging of gallstones. The plain film era, 1895-1924, was characterized by techniques that improved soft-tissue detail, allowing better detection of radiopaque stones. The contrast media era, 1924-1960, was initiated by the invention of IV cholecystography. In 1925, oral cholecystography was developed. During the era of expanding technology, 1960-1979, percutaneous transhepatic cholangiography, scintigraphy, and sonography came into use. The therapeutic era began in the 1980s.
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Crypt cell proliferation and HLA-DR expression in pelvic ileal pouches. To investigate the nature of the morphological changes that occur in ileal pouches, 26 biopsy specimens from patients with functioning ileo-anal pouches (eight with pouchitis) were studied. Normal ileum (n = 10) was used as a control. Mucosal morphometry (using linear measurements), crypt cell proliferation (CCP) (using the monoclonal antibody Ki67), and epithelial HLA-DR expression (monoclonal antibody CR3/43) were assessed. CCP (expressed as the percentage of Ki67 positive nuclei for each crypt) was significantly higher in pouches with pouchitis, compared with those without, and in pouches without pouchitis compared with normal ileum. CCP values in some pouches without pouchitis approached values found in those with pouchitis. CCP was related inversely to villous height and an index of villous atrophy (VH/TMT), and directly to crypt depth. In the presence of pouchitis there was intense epithelial HLA-DR expression that extended into the crypts. In some pouches with high CCP values, but without clinically important inflammation, surface epithelial HLA-DR expression was weak and patchy. It is concluded that villous atrophy and crypt hyperplasia in ileal pouches are associated with high CCP values. These may be increased even in the absence of active inflammation, and this increase may occur as a response to the new luminal environment.
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Routine and quantitative EEG analysis in Gilles de la Tourette's syndrome. Gilles de la Tourette's syndrome (GdlT) is a neurobehavioral disorder, with a reportedly high frequency of EEG abnormalities. We performed EEGs on 48 consecutive patients with GdlT, and frequency analysis in 26 patients (17 males), and compared the results with those from age- and sex-matched normal controls. Routine 18-channel EEG revealed minimal diffuse nonspecific slowing in only 3 of 48 patients (6%) and in 2 of 26 controls (7.7%). The frequency analysis of the EEG of the 26 GdlT patients and their normal controls showed similar brain activity. We conclude that no significant differences exist between the EEG activity in GdlT patients as compared with that in sex- and age-matched controls in routine as well as in quantitative EEG.
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Nuclear sclerotic cataract after vitrectomy for idiopathic epiretinal membranes causing macular pucker. We evaluated the occurrence or progression of nuclear sclerosis of the crystalline lens in 100 eyes after vitrectomy for removal of idiopathic epiretinal membranes causing macular pucker. The follow-up period ranged from six to 99 months (average, 29 months). Visually significant nuclear sclerosis was present preoperatively in three of the operated on eyes and four of the fellow eyes. The rate of occurrence or progression of visually significant nuclear sclerosis was far greater in the operated on eyes (P less than .0001). Of 100 patients, 80 operated on eyes and 24 fellow eyes had visually significant nuclear sclerosis or had undergone previous cataract extraction at the conclusion of the study. Different concentrations of glucose in the intraocular irrigating solution did not affect occurrence of later nuclear sclerosis. Patients older than 50 years of age had a far greater incidence of later nuclear sclerosis than patients younger than 50 years of age (P = .0003). Nuclear sclerosis may be caused by altered lens metabolism after removal of part of the vitreous gel, since nuclear sclerosis also occurs in other conditions associated with vitreous liquefaction.
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Adverse mortality experience of a southwestern American Indian community: overall death rates and underlying causes of death in Pima Indians. As part of an ongoing epidemiologic study, the death rate and causes of death during 1975 through 1984 were determined in Pima Indians who resided in the Gila River Indian Community (GRIC) in 1965 and later. Death certificates were available for 677 of the 681 deaths. In 78% of the deaths, the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records. The age- and sex-adjusted average annual death rate for the GRIC population (1639/100,000) was 1.9 times (95% CI 1.7-2.0) the 1980 rate for the U.S. all races (878/100,000). In Pima males, whose death rate was substantially higher than that of Pima females, the age-adjusted death rate was 2.3 times that in U.S. males, all races. Moreover among males 25-34 years of age, the Pima death rate was 6.6 times that for the U.S. all races. Diseases of the heart and malignant neoplasms caused 59% of U.S. deaths in 1980, but only 19% of GRIC deaths. By contrast, the age- and sex-adjusted mortality rate in the GRIC Pima was 5.9 times the rate of the U.S. all races for accidents, 6.5 times for cirrhosis, 7.4 times for homicide, 4.3 times for suicide, and 11.9 times for diabetes. Tuberculosis and coccidioidomycosis were important causes of death in the Pima, for whom infectious diseases was the tenth leading cause of death. The findings indicate that programs to improve the adverse mortality experience of the GRIC population should emphasize factors related to fatal accidents, alcoholic cirrhosis, homicide, suicide, diabetes mellitus, and infectious diseases. Young Pimas, especially the males, should be the primary focus of such preventive efforts. These findings and recommendations probably apply to many Native American populations.
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Insulinoma after streptozotocin therapy for metastatic gastrinoma: natural history or iatrogenic complication? Islet cell carcinoma frequently produces more than one chemical product, although its clinical expression is usually restricted to a single hormone. We describe an unusual patient who presented with full-blown metastasizing gastrinoma. He was treated with cimetidine for five years and then streptozotocin therapy, which resulted in a regression in hepatomegaly and a fall in serum gastrin levels. Following one year's therapy with streptozotocin, he was admitted in hyperinsulinemic hypoglycemic stupor. This appears to be the first reported case of a "shift" from clinical gastrinoma to insulinoma possibly related to prolonged streptozotocin therapy.
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Estimation of PR and ER by immunocytochemistry in breast cancer. Comparison with radioligand binding methods. Immunocytochemical assays for progesterone receptor (PR) using monoclonal antirabbit PR antibodies (PR-ICA) and for estrogen receptor (ER) (ER-ICA) were compared with radioligand binding (dextran-coated charcoal [DCC]) methods for receptor determination in patients with breast cancer. Immunocytochemical staining for PR was exclusively nuclear in localization. In this regard, PR staining is similar to previous findings for ER; PR-ICA showed a sensitivity of 89% and specificity of 100%. ER-ICA was also 89% sensitive and similarly specific. There was good correlation between the degree and intensity of staining and quantitative binding of radioligand. Receptor-positive tumors, however, show considerable variation of immunocytochemical staining, suggesting heterogeneity of cellular PR content. The availability of an immunocytochemical assay for PR increases the discriminatory potential for these methods of receptor determination.
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Fourth branchial pouch anomaly. We present an extremely rare case of fourth branchial fistula in a 23-year-old male. The characteristic clinical feature was a recurrent left lower neck abscess which did not respond to appropriate medical and surgical therapy. Radiography and a computed tomographic scan with contrast material revealed a fistula running from the apex of the left pyriform sinus (internal opening) to the left lower neck abscess. The fistula tract was excised surgically. Histological examination of the excised fistula revealed a squamous epithelial lining and subepithelial lymphoid tissue. This pyriform sinus fistula is thought to be of fourth pharyngeal pouch origin, because of its surgical aspects and the histological findings of the excised fistula.
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The relationship of pemphigus to neoplasia. A statistically increased incidence of malignancy has been observed in patients with pemphigus. A review of the literature reveals 42 cases of nonthymic malignancies and 18 cases of thymic malignancies. A significant predominance of men, with mean age at onset of 50 years, was observed. Pemphigus vulgaris is more common in patients with nonthymic neoplasms, whereas pemphigus foliaceus or pemphigus erythematosus and pemphigus vulgaris are equally common in patients with thymic neoplasms. Lymphoreticular malignancies, especially Kaposi's sarcoma, are most frequently observed. The majority of patients with nonthymic neoplasms have pemphigus before the detection of the malignancy and have a favorable 5-year survival rate after tumor resection. The majority of the patients with thymic neoplasms have a thymoma before the development of pemphigus. In some patients pemphigus develops after thymectomy and myasthenia gravis is often associated. Overall, 37 of the 60 patients, or 61%, had a neoplasm of the immune system.
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Comparison of anterior sphincteroplasty and postanal repair in the treatment of idiopathic fecal incontinence. Both postanal repair and anterior sphincteroplasty with levatorplasty have been advocated in the treatment of idiopathic fecal incontinence. To assess the functional results of these procedures, physiologic and radiologic measurements were carried out prospectively in 33 patients with idiopathic incontinence undergoing operative treatment, and 12 age- and sex-matched controls. Sixteen patients had anterior sphincteroplasty and levatorplasty and 17 had postanal repair. A satisfactory postoperative outcome was defined as perfect continence or incontinence of flatus only. Ten patients in the anterior sphincteroplasty group had satisfactory results (64 percent) and 10 in the postanal repair group (59 percent). Preoperatively, both groups had decreased resting and squeeze pressures, impaired and mucosal electrosensitivity, and marked pelvic descent vs. controls. Postoperatively, significant improvement in sphincter pressures and mucosal electrosensitivity was seen in both groups. No significant change in anorectal angle was demonstrated in the postanal repair group, whereas it was made significantly more obtuse in the anterior sphincteroplasty group. It is likely that the improved continence resulting from either of these two procedures is secondary to better anal sphincter muscle function and improved and sensation. It would appear that the anorectal angle is not crucial in maintaining continence.
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Angiographic arterial embolization and computed tomography-directed drainage for the management of hemorrhage and infection with abdominal pregnancy. Hemorrhage during or after surgery, pelvic abscess, bowel obstruction, and prolonged febrile morbidity can complicate the puerperal course of the gravida after removal of an extrauterine fetus with nondisturbance of the extrauterine placenta. In this report we describe the successful angiographic arterial gelfoam embolization of the placental vascular bed to control heavy postoperative hemorrhage in a mother suffering adult respiratory distress syndrome after removal of the fetal portion of her abdominal pregnancy. Six weeks later, computed tomography (CT)-directed drainage by catheter of a placental abscess was performed. Selective angiographic transcatheter embolization with gelfoam is a useful tool for the control of hemorrhage in the gravida who is an unfavorable operative candidate or who may present technical hemostasis problems peculiar to the placenta with abdominal pregnancy. Later use of CT-directed catheter drainage of the infected residual placental mass provided a nonoperative means of treatment.
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Bicarbonate-buffered lidocaine-epinephrine-hyaluronidase for eyelid anesthesia. A double-masked, randomized clinical trial was conducted to determine if subcutaneous eyelid injections of a bicarbonate-buffered lidocaine-epinephrine-hyaluronidase mixture were less painful than unbuffered injections. Twenty-one patients received both buffered (pH = 7.4) and unbuffered (pH = 4.6) injections. After each injection, patients recorded pain on a scale of 0, "no pain," to 10, "severe pain." Mean pain score for buffered injections was 2.0 versus 4.1 for unbuffered injections (P = 0.0003). Seventeen (81%) of 21 patients ranked the buffered injection less painful. Use of a bicarbonate-buffered lidocaine-epinephrine-hyaluronidase mixture is effective in making ophthalmic anesthesia less painful.
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Characteristics and biological role of steroid hormone receptors in neuroepithelial tumors Tissue samples from 57 patients with neuroepithelial tumors (25 glioblastomas, 18 anaplastic astrocytomas, and 14 astrocytomas) were analyzed in order to evaluate the presence of estrogen, progesterone, glucocorticoid, and androgen receptors. Glucocorticoid- and androgen-specific binding proteins were present in 38.6% and 21.6% of the cases, respectively. Only a few tumors showed estrogen or progesterone receptors. A correlation was found between grade of anaplasia, patient's sex and age, and presence of glucocorticoid and androgen receptors. The biological role of these two receptors was investigated in 10 primary cell cultures derived from neuroepithelial tumors. For this purpose, dexamethasone and testosterone were added to culture medium at different concentrations (from 50 to 0.016 micrograms/ml). A significant stimulation of the cell growth was observed in four of five glucocorticoid receptor-positive cultures when dexamethasone in doses ranging from 2 to 0.016 microgram/ml was added to the culture. No modulation of the growth was observed in glucocorticoid receptor-negative cultures at the same doses. Higher dexamethasone doses induced a significant decrease of the growth index independently from the glucocorticoid receptor status. All of the cultures tested for testosterone activity were negative for androgen receptors. This hormone induced an inhibition of the growth index at doses ranging from 50 to 0.4 micrograms/ml. The data suggest that neuroepithelial tumors contain specific glucocorticoid and androgen binding proteins. Glucocorticoid receptors modulate the growth of cultured neuroepithelial tumors in the presence of different concentrations of dexamethasone.
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Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.
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The presence of human papillomavirus type 16 in squamous cell carcinoma of the proximal finger and reconstruction with a bilobed transposition flap. In a 71 year old white female a clinically diagnosed keratoacanthoma on the dorsum of the right third finger was removed using Mohs micrographic surgery and histologically diagnosed as a squamous cell carcinoma. It was shown by dot blot hybridization to have HPV type 16 DNA in the tumor. The wound was reconstructed with a bilobed transposition flap.
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Does auxiliary heterotopic liver transplantation reverse hypersplenism and portal hypertension? In this study, performed to assess the effect of auxiliary heterotopic liver transplantation on portal hypertension and hypersplenism, eight patients with chronic liver disease who underwent the procedure and had functioning grafts for at least 6 months were analyzed. The transplantation resulted in (a) normalization of platelet and leukocyte counts, (b) reduction of splenomegaly by 20% +/- 3% (P less than 0.02), (c) disappearance of ascites, and (d) diminution of esophageal varices in all patients. Intraoperatively, the mean portacaval pressure gradient decreased with 54% +/- 7% after recirculation of the graft (P less than 0.05). In conclusion, a functioning auxiliary heterotopic liver graft decompresses portal hypertension and reverses hypersplenism.
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