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3895806
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One hundred and nine leprosy cases have been recorded by the service of dermatology in Sfax (the only specialised centre in the south of Tunisia) during the last decade. These cases have been essentially assembled in two regions: Sfax and Malloulech. The lag of their finding and the ignorance of some other new cases are due to several factors.
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3895815
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In many European countries hyperkinesis is a relatively rare clinical diagnosis compared with the United States. Though systematic international studies comparing the diagnostic process with regard to this disorder are still lacking, it is likely that the reasons for the vast differences in the rates of the disorder do not lie in the differences of the children's behaviour but in diagnostic practice. Individual components of hyperactivity, namely overactivity, restlessness and poor concentration are common among children attending clinics as well as in randomly selected samples in the general population. Treatment for hyperactivity is largely the same as for the majority of child psychiatric disorders which predominantly involve disturbances of conduct. As the 'causes', as well as the factors maintaining the symptoms, are often complex, one form of treatment is seldom adequate. In most cases a combination of psychological and educational treatments is necessary. Stimulant drugs, though in a few instances capable of producing instant and dramatic therapeutic effects, should not be used as a treatment of first choice.
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3895816
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No significant differences in plasma noradrenaline and adrenaline concentrations were found between 14 infants of diabetic mothers (IDMs) and 7 infants of non-diabetic mothers at birth or at 2 hours of age, although the mean values were higher in the IDMs. The mean blood glucose concentration declined from birth to 2 hours of age and it was lower at 2 hours of age in the IDMs although only one IDM became hypoglycaemic. Plasma non-antibody bound insulin concentrations were approximately 12 fold higher at birth and at 2 hours of age in the IDMs than in the control infants. Similar increases in plasma free fatty acids and free glycerol concentrations from birth to 2 hours of age were observed in the 2 groups. At 2 hours of age positive correlations were found between plasma noradrenaline and free fatty acids (r = 0.85, p less than 0.01) and free glycerol (r = 0.65, p less than 0.05) and between plasma adrenaline and free glycerol (r = 0.71, p less than 0.05) and the rise in free glycerol from birth to 2 hours of age (r = 0.65, p less than 0.05) in the IDMs. At birth positive correlations between plasma free fatty acids and plasma noradrenaline (r = 0.69, p less than 0.02) and plasma adrenaline (r = 0.88, p less than 0.01) were found in the IDMs. No correlations were found in the control infants. These findings indicate that the catecholamines counteracts the inhibitory effect of insulin on lipolysis in IDMs.
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3895805
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Having found a new case of leprosy from Beni Khadech, the Sfax Service of dermatology has decided to investigate in two places in this region: Elmenzla and Gattar. Beni Khadech, an endemic region, has 30 cases of leprosy in 1978 over 164 declared in Tunisia. Over 1688 systematically examined patients, 4 new cases have been discovered and 3 of which are contagious ones.
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3895817
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Samples of cerebrospinal fluid from 112 cases of suspected meningitis were tested for the presence of C-reactive protein (CRP), using a qualitative and quantitative slide test. Bacterial meningitis was confirmed in 34 patients, based on CSF and blood culture results, and/or elevated CSF white blood cell (WBC) count and typical biochemical profile. There were 8 patients with early onset, and 3 who had received prior antimicrobial therapy among the 5 neonates, 23 children, and 6 adults with bacterial meningitis. Organisms recovered from CSF, and/or blood, included Haemophilus influenzae 14, Streptococcus pneumoniae 9, Streptococcus group B-5, Staphylococcus aureus 2, E. coli 2 and Klebsiella pneumoniae 1. Slide test was positive for CRP in 33 cases, giving a sensitivity of 97% which compared favourably with elevated CSF protein 33%, decreased CFS glucose 64.7% CSF glucose/blood glucose less than 1/2, 85%, raised CSF WBC 38.2%, raised CSF PMN 61.7%, CSF culture positive 88.2%, and CSF gram-positive 82.5%. Slide test was positive for CRP in 1 of 78 CSF samples negative for bacterial meningitis, giving a specificity of 98%. It was concluded that testing of CSF for CRP is a simple, rapid and accurate method for the laboratory diagnosis of bacterial meningitis, which is particularly appropriate for areas lacking adequate laboratory facilities.
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3895818
|
Thirty children (age 3 months to 10 years) with complicated and uncomplicated lower urinary tract infections were treated with a single intramuscular injection of netilmicin 4.5 mg/kg. The diagnosis of lower urinary tract infection was based on the absence of fever and the presence of normal values for erythrocyte sedimentation rate, C-reactive protein concentration and urinary excretion of N-acetyl-beta-D-glucosaminidase. Follow-up urine cultures in all children demonstrated a cure rate of 97% and reinfection and relapse rates each of 7% respectively. The subgroup (12 children) with radiological abnormalities of urinary tract showed a cure rate of 92%, and reinfection and relapse rates of 9% respectively. The rates of cure, reinfection and relapse in the complicated and uncomplicated urinary tract infections were not statistically different (p greater than 0.05). A pharmacokinetic study (performed in 5 children) demonstrated that netilmicin urinary concentrations were over the MIC's of the infecting organisms up to 96 hours after the single-dose injection. Netilmicin was well tolerated and no side effects appeared during treatment. Single-dose netilmicin therapy is an effective and safe regimen for complicated and uncomplicated urinary tract infections in children. The response to single-dose netilmicin therapy seems to be related to its prolonged urinary elimination.
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3895819
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Mechanical ventilation with positive pressure has been implicated in the inappropriate release of vasopressin. To examine whether such a phenomenon occurs in infancy, 26 preterm neonates with Respiratory Distress Syndrome were studied. Simultaneous urine and plasma were collected for osmolality determination during mechanical ventilation with positive end expiratory pressure of 4-8 cmH2O. Results were plotted onto our previously described nomogram. The data show normal distribution of plasma to urine osmolality ratio in 25 out of 26 infants. These results do not support the common belief that positive pressure mechanical ventilation in the newborn with RDS provokes inappropriate secretion of vasopressin.
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3895821
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A study on the evaluation of staining findings of immunofluorescence in unfixed or fixed renal biopsy specimens is described. Renal biopsy specimens obtained from ten patients with IgA nephropathy and membranous nephropathy were embedded in gelatin or paraffin matrix. Renal biopsy specimens embedded in paraffin matrix were digested with 0.05% protease. The specimens were stained with FITC-conjugated anti-human IgA, IgG, IgM or C3 antisera at 4 degrees C overnight. IgA, IgG or IgM were markedly observed in glomeruli using unfixed materials embedded in gelatin matrix or 10% neutral buffered formalin fixed materials embedded in paraffin matrix from patients with IgA nephropathy and membranous nephropathy. There was no significant difference in the intensity or distribution of IgA, IgG or IgM deposition among the two different conditions of immunofluorescence in patients with such diseases. Although the deposition of IgA using unfixed materials embedded in gelatin matrix was prominently coarse granular or lumpy in glomeruli from patients with IgA nephropathy, that of IgA using 10% formalin fixed materials embedded in paraffin matrix was fine granular and/or interrupted linear in glomeruli. It was suggested that the immunofluorescence in renal biopsy specimens embedded in paraffin matrix after digestion with protease is useful for the evaluation of immunoglobulins in glomeruli from patients with IgA nephropathy or membranous nephropathy.
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3895822
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HNK-1, a murine monoclonal antibody, is known to react with most of the natural killer (NK) and killer (K) cells in peripheral blood. Cells reacting with this antibody (HNK-1+ cells) were studied on tissue sections of ninety two cases of malignant lymphomas (MLs) by using immunoperoxidase technique, in an attempt to elucidate the role of this type of cells in MLs. Follicular lymphomas were found to be highly infiltrated with HNK-1+ cells. The mode of infiltration in follicular lymphomas is just like in normal germinal centers. Many cases of diffuse lymphomas with cleaved nuclei, indicative of diffuse B-cell lymphomas of follicular center cell origin, as well as diffuse ML with heavy fibrosis (sclerosis) or histiocytic reaction, were also found to be infiltrated with abundant HNK-1+ cells. Meanwhile, other types of B-cell ML and all types of T-cell ML, as well as Hodgkin's disease, were shown to be very poor in HNK-1+ cell reaction. From a prognostic viewpoint, the low grade malignancy group in the NCI Working Formulation or Kiel Classification was found to be infiltrated with significantly much more HNK-1+ cells as compared to the high grade malignancy group. The significance of these findings are discussed, with the stress on the possible suppressive function of HNK-1+ cells on proliferation and differentiation of follicular center cell type B-cell MLs.
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3895823
|
Three cases of primary splenic lymphoma (two diffuse large cell (DL) lymphomas; and one follicular mixed small cleaved and large cell (FM) lymphoma according to the Working Formulation) are presented. Histologically as well as immuno-histochemically, all were considered to be of follicular center cell origin. Reticulin stains clearly demonstrated that the white pulp was primarily involved both in FM and DLs. Remnants of clusters of dendritic reticular cells were demonstrated immuno-histochemically in one case of DL. Primary splenic lymphomas in the Japanese literatures were reviewed and compared with those in the American literatures. It was found that "solitary mass" was the predominant gross feature (81%) and "reticulum cell sarcoma" was the predominant histologic type (66%) in Japan. In the United States, lymphosarcoma was the predominant histologic type (39%), reflecting the histologic distribution of nodal lymphomas, and "homogeneous" or "miliary" was the predominant gross feature (71%).
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3895826
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Urinary kallikrein excretion (UKal), determined by the esterase method, was measured in 10 normotensive volunteers, 10 patients with essential hypertension and in 7 patients with primary aldosteronism before and after operative removal of the adenoma. UKal values were low in 5 of the patients with essential hypertension. Preoperative UKal values in the patients with aldosteronism did not differ significantly from those of the normal subjects, but decreased in all after operation in parallel with changes in urinary excretion of tetrahydroaldosterone and plasma aldosterone concentration. The study supports the assumption of an association between the renal kallikrein-kinin system and the mineralocorticoid state in man.
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3895828
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Eighty patients with deep vein thrombosis (DVT) were randomized between our routine duration of oral anticoagulation and 50% reduction thereof, in order to evaluate whether shorter therapy could be given without increased risks. The study was stratified, so that 20 patients with the 1st episode of DVT caused by a temporary risk factor were treated for 1.5 or 3 months, 40 patients with the 1st episode of DVT caused by a permanent risk factor for 3 or 6 months, and 20 patients with the 2nd episode of DVT for 6 or 12 months. When warfarin therapy was discontinued, the patients were followed by means of venous occlusion plethysmography every 3 months for 1 year, and clinically for 15-27 months in the different subgroups. Thromboembolic complications were registered and verified by venography and perfusion lung scan. We could not detect any difference between the groups. The rate of rethrombosis and embolism during 12 and 24 months after cessation of anticoagulant therapy was 8 and 10%, respectively, among the patients with reduced duration of treatment and 8 and 14%, respectively, among those with regular duration. One fatal, warfarin-induced hemorrhage occurred. It is important to reduce unnecessary extension of oral anticoagulation after DVT in order to minimize the negative side-effects without increasing the recurrence rate. More extensive trials should be performed to confirm our results and define the optimal duration of treatment.
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3895827
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This controlled investigation of 27 volunteers compared the effect of cold and lukewarm tap water and carbonated water on the passage through the esophagus of a large circular tablet containing barium sulphate and of the same size and specific gravity as an acetylsalicylic acid tablet (Kodimagnyl). The influence of yoghurt on the passage of the same tablet was also examined. The investigation emphasized the importance of taking tablets together with 100 ml of liquid. A comparison of the transit times for tablets taken together with 100 ml of cold carbonated water and 100 ml of lukewarm tap water showed a significantly better passage when the tablets were taken with cold carbonated water (p = 0.01). A similar advantage of carbonated liquids was seen when tablets were taken with 25 ml of lukewarm tap water as compared with 25 ml of cold carbonated water (p = 0.01). Administration of a tablet in a tablespoon of yoghurt is a good alternative, even though the bioavailability of certain preparations may be reduced.
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3895829
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Complete recovery from deep brain abscesses was achieved in four patients treated by a specialized stereotactic method. In one patient the lesion was in the right thalamus, in two patients within the brain stem and in one case in the right rolandic cortex. The technique consists in the stereotactic implantation of a chronic intracavitary catheter connected to a subcutaneous reservoir to allow postoperative multiple evacuations and local antibiotic irrigations. Serial CT scan examinations guided the timing of intracavitary treatment and the removal of the catheter. No recurrence developed. The diagnostic and therapeutic advantages of this stereotactic technique are emphasized.
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3895849
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In contrast to true hemangiomas, which are vascular neoplasms, port-wine stains (PWS) are vascular malformations. They consist of mature teleangiectatic vessels in the dermis and the adjacent subcutis. The series of 50 patients here reported have been treated by subtotal excision of their PWS, covering the resulting defects with carefully selected full-thickness skin grafts.
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3895850
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Based on prior experience with implant exposure, an aggressive regimen to eradicate periprosthetic infections has proven successful in delayed gram-positive and gram-negative bacterial infections and in atypical microbacterial infections. The objective of the "salvage" procedure is to retain a prosthesis, to maintain breast contour, and to avoid psychological and physical consequences of prosthesis removal. The "salvage" procedure involves topical antisepsis, contracture release if needed, systemic and topical antibiotics with intermittent or continuous irrigation, and reinforcement of incision lines in selected cases using local tissue flaps.
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3895848
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The authors discuss the history and use of injections of paraffin, silicone, and collagen for soft-tissue contouring. The structure and uses of collagen are described with particular reference to Zyderm Collagen Implant, a highly purified bovine collagen.
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3895852
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The presence of Thomsen-Friedenreich antigen (T-Ag) against bladder mucosa in bladder tumor cases and control individuals was examined by the immunoperoxidase and the immunofluorescein method using labelled lectin. T-Ag was negative in all 15 cases of non-malignant bladder epithelium, and positive on the cell surface after sialidase treatment (cryptic T-Ag positive). In the 37 out of 72 bladder tumor cases, however, cryptic T-Ag was positive, and in the remaining 35 cases T-Ag was positive or negative after sialidase treatment. Furthermore 55 cases which had received the first treatment by TUR-Bt were investigated. Thirteen of the 31 cryptic T-Ag positive cases recurred during observation after operation whereas 22 of the 24 T-Ag positive or cryptic T-Ag negative cases recurred, the rate being significantly higher for the latter. In addition, the disease-free interval was absolutely longer in the cryptic T-Ag positive cases than in T-Ag positive or cryptic T-Ag negative cases. The exploration of T-Ag in bladder cancer may be valuable for predicting the clinical course after TUR-Bt.
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3895853
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The presence of bacteria at the renal pelvis and the methods of their detection were studied in 11 patients with catheter-free cutaneous ureterostomy (tubeless ureterocutaneostomy). These patients had had total radical cystectomy due to bladder carcinoma. Of these, 5 patients had single-sided stoma with 9 kidney-ureter units and 6 patients had bilateral stoma with 10 units, excluding 2 ureters because of indwelling catheters. The urine obtained both from the renal pelvis with a single lumen catheter and from the pouch were used in the bacterial culture test and urinalysis. The aseptic swab after touching the skin around the stoma was also cultured for bacteria. Of 19 kidney-ureter units, 9 (47%) were found to have bacteria in urine obtained from catheterization. However, only 2 units (11%) were observed to be accompanied with pyuria. In this method, the rate of bacterial appearance was higher in single-sided stomas than in bilateral ones. There was no statistical correlation between the presence of hydronephrosis and the rate of bacterial appearance. In conclusion, the method of single lumen catheterization might be of great use for analysis of urinary tract infections in patients with such conditions.
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3895854
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Hepatic cavernous hemangiomas are benign tumors of the liver that are often an incidental finding. They are usually asymptomatic but may cause symptoms when traumatized, may bleed spontaneously, or may produce pain by virtue of their large size and mass effect. A retrospective analysis of the clinical presentation, liver function tests, and diagnostic imaging procedures in 20 patients with hepatic hemangiomas is presented and the literature is reviewed. The 20 patients had 27 mass lesions as seen on liver scintigraphy, computed tomography, or sonography. Technetium-99m-labeled red blood cell flow studies and blood pool scintigrams showed delayed filling of the mass lesions, diagnostic of hemangiomas. This finding was not encountered in any other type of lesion. A new diagnostic algorithm is proposed in which blood-flow and blood-pool scintigraphy play a more prominent role in the diagnostic workup. According to this algorithm, if liver function tests in a patient with hepatic mass are either normal or abnormal and suggestive of hepatocellular dysfunction, the patient should undergo hepatic blood-flow and blood-pool studies.
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3895855
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Computed tomography (CT) has been used to detect a variety of gallbladder abnormalities, but the accuracy of routine abdominal CT in evaluating intracholecystic bile has not been established. Forty-six patients were identified in whom abdominal CT and sonography were performed within 1 week of each other. Using sonographic results as the standard, sensitivity, specificity, and accuracy of CT gallbladder evaluation were calculated; both initial CT interpretations and retrospective review of scans were used for this analysis. In the retrospective review, visual interpretation of gallbladder images and measurement of intracholecystic bile attenuation (greater than or equal to 25 H, abnormal) were analyzed. The overall sensitivity of CT in detecting abnormal gallbladder contents ranged from 44% (bile attenuation greater than or equal to 25 H) to 63% (retrospective CT interpretation), while specificity ranged from 77% to 93%. The most common cause of high-attenuation bile in the series was sludge, a cause not previously reported. It was concluded that intracholecystic bile is poorly evaluated on routine abdominal CT, particularly because of low sensitivity in disease detection.
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3895856
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With the routine use of sonography in the evaluation of suspected gallbladder disease, the familiarity of gallbladder duplication and its differential considerations are essential. Three cases are presented: one surgically proven duplication of the gallbladder, one case in which the sonographic findings were compatible with duplication of the gallbladder, and one surgically proven intraperitoneal fibrous band mimicking a gallbladder duplication. Gallstones were present in all cases and were confined to only one of the two lobes identified in each case. The gallstones did not communicate between individual gallbladder lobes despite multiple patient positions. Contraction of the non-stone-containing lobe was present in one nonfasting patient, which is probably the best indirect sign of a double gallbladder.
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3895858
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Medullary sponge kidney is reported in six children aged 2-18 years. One child was asymptomatic; the others had hematuria or a urine-concentrating defect. Renal function and size were otherwise normal, as was liver function. The diagnosis was made at excretory urography according to criteria established in adults. Sonography revealed hyperechogenic pyramids, at first at the periphery, later generalized. Computed tomography proved this to be calcium. Medullary sponge kidney is rare but exists in children. Sonography is very sensitive to the pyramidal nephrocalcinosis that complicates this disease and explains the frequent presenting symptom of hematuria in these children.
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3895857
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The plain abdominal radiographs of 28 patients with acute gastrointestinal graft-vs.-host disease (GVHD) were examined to determine the plain radiographic findings associated with this disorder. These findings, in order of decreasing frequency, included air-fluid levels, bowel wall/mucosal fold thickening, gasless abdomen, bowel dilatation, pneumatosis intestinalis, and ascites. When a number of these findings are present, the plain abdominal radiographs may be sufficiently characteristic to suggest gastrointestinal GVHD. Differentiating acute gastrointestinal GVHD from small-bowel obstruction is often of major clinical importance. Fortunately, the bowel gas pattern in acute gastrointestinal GVHD rarely suggests obstruction and, thus, bowel obstruction can usually be excluded on the basis of plain radiographs alone.
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3895859
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Thirty-seven patients with thoracic and lumbar spine fractures were treated with Harrington rod instrumentation (HRI), and the progress and results of that surgery were monitored with intraoperative spinal sonography (IOSS). Adequate neural tissue decompression and spinal column alignment was achieved in less than one-half (14/31, 45%) of the patients in whom HRI was performed as the first step of the surgical procedure. As a result of these findings, further surgical maneuvers were performed which, in most cases, resulted in adequate spinal realignment and neural tissue decompression. In six patients, direct surgical reduction of displaced bone fragments was performed before HRI. Since total decompression of neural tissue may be important in patients with spinal cord or cauda equina injuries, it is recommended that IOSS be used in all cases of HRI for thoracic and lumbar spine fractures. The need to perform additional surgical maneuvers to accomplish neural tissue decompression may be obviated if intraoperative sonography shows adequate decompression with HRI alone.
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3895860
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The therapeutic response to treatment of lumbar disk herniation with chymopapain chemonucleolysis is significantly influenced by the criteria used for patient selection. Although careful clinical selection of patients reduces the frequency of treatment failure, some patients do not achieve satisfactory relief of pain with chemonucleolysis. In an attempt to identify objective pretreatment radiographic findings that might refine selection criteria and further reduce the failure rate of chemonucleolysis, a retrospective correlation of pretreatment radiographs and clinical responses was made of 200 consecutive chemonucleolysis patients. Marked improvement in sciatica occurred in 79.9% and 79.3% of patients at early and late follow-up, respectively. There was a significantly higher response rate, however, in patients who had definite radiographic evidence of focal disk herniation and in those patients with definite radiographic evidence of nerve-root compression (marked nerve-root deviation, nerve-root flattening or edema, root-sleeve amputation) by disk material. Those patients with a preinjection disk height greater than the mean had a slightly better response rate (91.1%) than those whose disk height was smaller than the mean (80.0%). Most cases of treatment failure could be attributed to an incorrect radiographic diagnosis, treatment of patients with equivocal diagnostic studies, the presence of "free" disk fragments, and causes of nerve-root compression unresponsive to chymopapain.
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3895861
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Chymopapain chemonucleolysis is now used extensively in this country to treat lumbar disk herniation. Despite increasing experience in patient selection, there continue to be patients who do not respond to treatment and require diagnostic reevaluation. Interpretation of postchemonucleolysis computed tomographic (CT) scans in these patients requires a knowledge of the CT changes that normally occur after treatment with chemonucleolysis. To define these temporal changes, a prospective CT evaluation was performed of 29 treated interspaces in 26 patients who returned for routine postchemonucleolysis follow-up. Despite a successful clinical response in 17 of 21 patients, changes in the size, location, shape, homogeneity, and density of the disk herniation were uncommon at the 6 week follow-up. In 24 treated interspaces, the most common changes at 6 week CT follow-up were the development of vacuum phenomenon in three (12.5%) and a slight decrease in the size of two (8.3%) disk herniations. A successful response was noted in 17 of 21 patients scanned at 6 month follow-up, with five (22.7%) of 22 injected interspaces exhibiting vacuum phenomenon and 13 (59.1%) interspaces showing an observable decrease in the size of the disk herniation. Early improvement of sciatica after chemonucleolysis often occurs without a change in the size of the disk herniation and may be mediated by chymopapain-induced disk-space narrowing. Continued improvement may be accompanied by both a decrease in the disk height and a reduction in the size of the disk protrusion.
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3895864
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Xenon-133 postperfusion lung scintigraphy using 10% windows was compared with standard posterior preperfusion 133Xe ventilation scanning in 33 patients. The postperfusion 133Xe study identified all major defects and washout abnormalities. In five patients, the assessment of match or mismatch of defects was improved because of optimal positioning of the postperfusion ventilation study. Computer subtraction of background technetium-99m macroaggregated albumin activity improved detection of mild washout abnormalities in eight patients but did not change the diagnostic category in any case. Postperfusion ventilation scanning using 10% windows (with or without background computer subtraction) is an alternative to preperfusion ventilation scanning for major V/Q abnormalities.
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3895865
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Review of 713 renal transplant patients at the Medical College of Wisconsin yielded 17 (2.3%) with spontaneous colon perforation. The cause seemed to be related to nonocclusive ischemia in the majority of cases (nine). The sigmoid colon was the most common site of perforation (nine cases). The early detection of colon perforation suspected on radiographic examination was associated with improved survival statistics.
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3895866
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The radiology of the ileoanal reservoir based on a study of 50 consecutive patients is presented. Small-bowel obstruction (12%) and leakage at the ileoanal anastomosis (8%) were detected most commonly. Partial outlet obstruction from reservoirs fashioned from three segments of terminal ileum was noted radiographically as a common problem unique to this form of ileoanal reservoir. Superior mesenteric artery syndrome (6%), pelvic abscess (4%), pouch-vesicular fistula (2%), and several other problems were less frequent.
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3895868
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Intrahepatic calculi in non-Asian patients were studied by sonography and computed tomography (CT). Three patients were studied by CT cholangiography also. In two cases, the calculi were consecutive to Caroli disease, and in two others, the biliary stones were formed proximal to a stenosis of a previous surgical anastomosis. Five patients spontaneously developed intrahepatic calculi. All sonograms were abnormal. Image specificity was good, even when bile ducts were not dilated, if appropriate technique allowed identification of a double-arc-shadow pattern. Sonography strongly suggested the diagnosis in eight patients and was nonspecific in only one. On CT, calculi had various densities, and they were not visible in two patients. CT cholangiography was not particularly helpful. Finally, CT added little more information when performed after sonography. Both examinations strongly underestimate the number of stones, and direct cholangiography remains indicated if surgery is planned.
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3895867
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Real-time sonography was used to examine the biliary tracts of 103 pregnant women. Common hepatic duct size, degree of right hydronephrosis, and presence of gallstones were noted. There were three important observations: (1) The top normal size of the common hepatic duct was 5 mm; (2) no correlation was found between common hepatic duct size and stage of pregnancy or degree of right hydronephrosis; and (3) gallstones were incidentally noted in 3.9% of patients.
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3895869
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Reports of echogenicity of the fetal lung as it relates to maturity of that organ are scant and at variance. A study was undertaken to determine if any correlation between fetal age and/or lung maturity and echogenicity could be determined in a clinical setting. Studies were performed with either linear array or mechanical sector real-time devices. Echogenicity of the fetal lung was compared with that of the fetal liver in the same longitudinal (parasagittal or coronal) sonogram. Lung echogenicity was judged to be hypodense, isodense, slightly hyperdense, or markedly hyperdense as compared with the liver texture. One hundred eighty-five studies were evaluated; of these, some 37 patients also underwent amniocentesis for determination of lecithin/sphingomyelin ratios (L/S) and presence of phosphatidyl glycerol (PG). Linear regression analyses were performed to determine if lung echogenicity would serve as an indicator of fetal maturity. No clinically applicable relation was established between fetal lung echogenicity and gestational age, L/S, or presence of PG in amniotic fluid with current methodology. The possibility persists that tissue characterization techniques may find application in such an investigation.
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3895872
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In 122 children (ages, newborn to 17 years) without urinary tract disease, 244 kidneys were examined sonographically. Renal length and volume were measured and correlated with age, body weight, height, and total body surface area, permitting preparation of nomograms with predicted means and 95% prediction intervals. Also evaluated were renal parenchymal echogenicity, medullary pyramids, and central sinus echoes, and the appearance of each was correlated with age.
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3895874
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Neonates are susceptible to infection since several elements of the immune system are deficient. At present, the most common pathogens are Group B streptococci and Escherichia coli. Prolonged rupture of membranes with amnionitis is a high-risk setting. Clinical signs suggesting neonatal sepsis include respiratory distress, poor feeding, hypothermia, seizures and hypotonia. After the sepsis work-up is completed, the initial choice of antibiotics is based on the prevailing organisms and antibiotic sensitivities within the community.
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3895877
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The acute hemodynamic effects, long-term clinical efficacy, and safety of the oral angiotensin-converting enzyme inhibitor, captopril, were assessed in a multicenter cooperative study of 124 patients with heart failure resistant to digitalis and diuretics. The cardiac status of most patients was deteriorating prior to the study. Favorable acute hemodynamic effects consistently occurred with captopril. Maximal mean percentage increases in cardiac index, stroke index, and stroke work index were, respectively, 35%, 44%, and 34%. Systemic and pulmonary vascular resistances were each decreased by approximately 40%, as were the filling pressures of the right and left heart. Infusion of nitroprusside in some of the same patients to an end point of a pulmonary capillary wedge pressure of 12 to 18 mm Hg (equivalent to that after captopril) revealed no significant difference in the effect of either drug on the other hemodynamic parameters. Recatheterization after 8 weeks of captopril therapy revealed sustained hemodynamic changes. Significant and sustained improvements in clinical status were observed in most patients as measured by changes in New York Heart Association (NYHA) functional classification and exercise tolerance times. Seventy-nine percent of patients for whom there were adequate NYHA class data improved. Twenty percent remained unchanged and 1% deteriorated. Those patients who had both pretreatment and post-treatment exercise stress testing exhibited a highly significant mean increase in exercise tolerance times of 34% (317 +/- 32 seconds pretreatment to 425 +/- 34 seconds, final measurement). There was no evidence of tachyphylaxis over an 18-month period.(ABSTRACT TRUNCATED AT 250 WORDS)
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3895878
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Clinical trials of intravenous amrinone were performed in 462 patients severely ill with congestive heart failure. All were monitored invasively. Adverse reactions were complicated by underlying disease severity and concomitant drug therapy. No consistent pattern of arrhythmias emerged in relation to intravenous amrinone administration. Thrombocytopenia was noted in 2.4% of patients, but it was asymptomatic with no demonstrable bone marrow depression or antiplatelet antibodies. Gastrointestinal adverse effects, hypotension and fever were rare, each occurring in fewer than 2% of patients. Liver enzyme alterations were seen in 1 patient, but it could not be determined whether these changes were related to intravenous use of the drug. Chest pain and irritation at the site of injection were noted in 1 patient each. Spontaneous anecdotal postapproval reports cited tachycardia, liver enzyme elevation, thrombocytopenia, intravenous site irritation, failure to respond and anaphylactoid response as adverse effects or possible adverse effects; each was mentioned in 3 or fewer reports. Drugs contraindicated for concomitant use with intravenous amrinone are listed, and chemical interactions with glucose solutions and intravenous furosemide are discussed.
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3895876
|
The purpose of this study was to evaluate whether the degree of valvular regurgitation could be reliably estimated by digital subtraction angiography using a 0 to 4+ scale of measurement identical to that applied in conventional cineangiography. Thirty-seven sets of angiograms, each consisting of a digital subtraction angiogram (DSA) and a cineangiogram (CINE) were obtained from 33 patients. Twenty-three angiogram sets were obtained from the ventricles, while 14 were performed in the ascending aorta. Both DSA and CINE images were analyzed for regurgitation by two independent observers. A weighted kappa statistical analysis, carried out to determine the extent to which the two observers agreed on DSA and CINE assessments, demonstrated excellent agreement. The degree of atrioventricular valve regurgitation manifested by DSA was not significantly different from that determined on CINE for either Observer A or B (1.8 +/- 1.2 by CINE vs 2.1 +/- 1.5 by DSA, 2.1 +/- 1.4 vs 2.5 +/- 1.0, respectively). However, occasional exceptions occurred in which the degree of atrioventricular valve regurgitation was overestimated by DSA as compared to CINE. Conversely, in 12 cases with aortic regurgitation, DSA overestimated the grade of regurgitation compared to CINE, 2.3 +/- 1.1 by CINE vs 3.2 +/- 0.8 by DSA (p less than 0.01) for Observer A and 2.1 +/- 1.2 vs 3.0 +/- 1.0 (p less than 0.01) for Observer B. The phenomenon which best explains these data is the occurrence of digital enhancement of myocardial opacification produced by coronary perfusion radiocontrast during angiography.(ABSTRACT TRUNCATED AT 250 WORDS)
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3895879
|
The Jenkins Activity Survey (JAS), a questionnaire developed to assess the type A behavior pattern, was administered to 2,314 participants in the Aspirin Myocardial Infarction Study. All had a myocardial infarction (MI) before entering the study and were followed for at least 3 years. The JAS type A score was not significantly related to risk of recurrent major coronary events (definite nonfatal MI and coronary death) in the group of 244 women, the group of 2,070 men, or the subgroup of 671 men who were employed full-time in professional, technical or managerial positions. These results indicate that the JAS type A score is not useful in assessing prognosis after MI. By inference, traits measured by the JAS type A score, such as competitiveness, orientation toward achievement and preference for a rapid pace of life, appear not to be associated with increased risk of recurrent major coronary events.
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3895875
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Four hundred two patients with suspected myocardial infarction seen within 6 hours of the onset of symptoms entered a double-blind randomized trial of lidocaine vs placebo. During the 1 hour after administration of the drug the incidence of ventricular fibrillation or sustained ventricular tachycardia among the 204 patients with acute myocardial infarction was low, 1.5%. Lidocaine, given in a 300 mg dose intramuscularly followed by 100 mg intravenously, did not prevent sustained ventricular tachycardia, although there was a significant reduction in the number of patients with warning arrhythmias between 15 and 45 minutes after the administration of lidocaine (p less than 0.05). The average plasma lidocaine level 10 minutes after administration for patients without a myocardial infarction was significantly higher than that for patients with an acute infarction. The mean plasma lidocaine level of patients on beta-blocking agents was no different from that in patients not on beta blocking agents. During the 1-hour study period, the incidence of central nervous system side effects was significantly greater in the lidocaine group, hypotension occurred in 11 patients, nine of whom had received lidocaine, and four patients died from asystole, three of whom had had lidocaine. We cannot advocate the administration of lidocaine prophylactically in the early hours of suspected myocardial infarction.
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3895881
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Twenty dogs were studied to characterize the anatomic, hemodynamic and pathologic effects of catheter-delivered cardioversion (CDCV) in the left ventricle. Five dogs each received 1 CDCV of either 50, 100, 200 or 300 J at the left ventricular apex. The injury occurred at the posteroinferior apex. Structural integrity of the ventricle remained intact. Energy doses of 50 and 100 J resulted in focal subendomyocardial injury. Higher energy levels resulted in localized transmural injury. There was a linear dose-related correlation between the volume of injury and delivered energy. Electrocardiographic changes were seen immediately in all dogs. Fifteen dogs had acute, transient ventricular arrhythmias. One dog died with refractory arrhythmias. Minimal hemodynamic changes were associated with the CDCV. Unique histopathologic changes were observed. Thus, local tissue destruction can be produced with CDCV. The extent of injury is dose-related and is associated with minimum hemodynamic changes. The lesion may be acutely arrhythmogenic.
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3895880
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Nine men with chronic stable congestive heart failure (New York Heart Association class II or III) were studied. Oxygen consumption was measured continuously and cardiac output (CO) determined by thermodilution and from the Fick equation at the end of each stage of treadmill exercise. CO measured by the 2 techniques was similar (r = 0.98) over the range of 2.5 to 13 liters/min (43 separate estimations). Tricuspid regurgitation developed in 2 patients during exercise, which resulted in unphysiologic estimates of CO (more than 30 liters/min) by thermodilution. In these circumstances estimation of CO by the direct Fick technique is superior. With this exception, CO measured by thermodilution was accurate even during exercise and provided results similar to those using the direct Fick technique.
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3895883
|
The effects of boiled water extracts of clonorchicidal raw drugs screened by the EPG counts in vivo on the structure of Clonorchis sinensis were investigated. The extracts of Cassia obutusifolia and Dictamnus dasycarpus did not seem to induce the morphological changes of the worms, and in those of Machilus thunbergii and Prunús mume, widening of bladder to lower level of seminal receptacle was visible without any other changes. Those of Inula helenium and Saussurea lappa, however, disclosed regressive and progressive changes as degeneration, atrophy, necrosis, dilatation, etc. of viscera of the worms. The recover rates of the worms from experimentally infected rabbits administered with the extracts of I. helenium and S. lappa for 30 days, beginning at the 3rd day of inoculation, were as low as 2% and 2.8%, respectively.
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3895884
|
Indian and Chinese cosmic elements are five. They originate from a common source, Bralrma in Indian and Thai-chi in Chinese. The first created element is Mu = Tree, not wood, and life-form itself, immovable but moves everything else = Akaska in Indian cosmology. Dryness = Metal in Chinese, Moisture = Earth. Fire as Heat and Water as Cold, are common to both systems.
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3895885
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A drug of longevity, prior to alchemy, was peach, from which the god of longevity has emerged. Alchemy began by synthesizing red colloidal gold with gold to make the body ever-lasting and redness, as soul, to make life eternal. Its climax was reached with cinnabar-gold, which is blood-red, while red-gold is only brick-red. It was called Makaradhwaja in India. There have been fertility gods. Hermes was one and Alchemy has been named a hermetic art. Makara was crocodile-cum-fish, god of fertility. Makaradhwaja means Emblem of god of fertility, signifying a drug conferring vigour of youth.
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3895887
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B- and T-lymphocytes were studied in patients with sickle cell anemia. Samples were analyzed during asymptomatic periods and during vasocclusive pain crises to assess a possible relationship to these periods. Assays of B-cell function and quantitation of B- and T-lymphocytes and their subsets were carried out. During crises, six of the eight patients showed a significant decrease in the number of immunoglobulin-producing cells, together with normal or enhanced blastogenic responses. The total number of T-lymphocytes was normal when measured by the monoclonal antibody OKT3 in contrast to the significantly lower level observed in some patients, as determined by the E-rosette technic. There were no significant changes in the percentage of either helper or suppressor T-cells or in the percentage of B-cells. The results show that changes in in vitro B-cell function occur during vasocclusive pain crises in patients with sickle cell anemia. These may be clinically important in these patients.
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3895886
|
A morphologic, histochemical, and immunocytochemical study of 20 cases of pure gastrointestinal carcinoids, adenocarcinomas, and mixed neoplasms composed of both elements, so-called composite carcinoma-carcinoid tumors (CCC), was undertaken in order to correlate the morphologic patterns with the immunocytochemical localization of carcinoembryonic antigen (CEA), serotonin, and a battery of polypeptide hormones (calcitonin, glucagon, insulin, gastrin, somatostatin, and adrenocorticotropin [ACTH]). Paraffin sections from five pure carcinoids, seven pure adenocarcinomas, and eight CCC from the stomach, small bowel, appendix, and colon were studied with mucicarmine, silver impregnation stains, and a peroxidase-anti-peroxidase technic. Of the eight CCC, all were mucin positive, four were argyrophilic, and three were argentaffin positive. CEA was present in all eight, serotonin in seven, and calcitonin in one. No other neurohormonal peptides were demonstrated. The distribution of serotonin and CEA generally corresponded to the morphologic pattern, but discordance was observed in two cases, i.e., serotonin was not always localized to areas of carcinoid and CEA not always confined to areas of carcinoma. All five pure carcinoids demonstrated intracytoplasmic localization of serotonin, whereas none contained intracytoplasmic CEA. In two cases, CEA was present within acinar lumens only. The seven colonic adenocarcinomas were argyrophil and argentaffin negative. All contained CEA within the cytoplasm and in gland lumens. None contained serotonin. None of the neurohormonal peptides was localized in either pure adenocarcinomas or carcinoids. This study reveals that among gastrointestinal neoplasms displaying morphologic patterns of adenocarcinoma and carcinoid, immunocytochemical localization of CEA and serotonin confirms their bidirectional differentiation and justifies the designation "composite carcinoma-carcinoid."
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3895888
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A rapid Spot-CAMP test was evaluated for its ability to accurately identify colonies of Streptococcus agalactiae (Lancefield Group B) growing on primary sheep blood agar plates. The test uses a beta-lysin-containing filtrate, which is prepared from a broth culture of Staphylococcus aureus. A drop of beta-lysin filtrate is applied adjacent to a suspected group B Streptococcus (GBS) colony and the plate is incubated and then examined for a zone of synergistic hemolysis. The Spot-CAMP test demonstrated 100% correlation with both a Standard CAMP procedure and Lancefield serogrouping. The rapid Spot-CAMP test was easy to perform and inexpensive, and could presumptively identify within 30 minutes colonies of GBS growing on primary isolation plates.
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3895889
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A fixed combination of erythromycin ethylsuccinate and sulfisoxazole acetyl (erythromycin-sulfa) was compared with amoxicillin for the treatment of acute otitis media (AOM) in children. Of 145 patients studied, 76 boys and 69 girls were compliant and were evaluated for drug efficacy (72 amoxicillin, 73 erythromycin-sulfa). Based on otoscopic and tympanometric results, cure rates at ten to 14 days for AOM due to all organisms were 83% (63/72) for amoxicillin and 89% (65/73) for erythromycin-sulfa; for Haemophilus species (including mixed infections), they were 84% for amoxicillin (26/31) and 83% for erythromycin-sulfa (20/14). Cure rates for ampicillin-resistant Haemophilus were 1/1 for amoxicillin and 7/8 (88%) for erythromycin-sulfa; one patient (12%) had persistent AOM at day 10. Of the patients with AOM due to Streptococcus pneumoniae, 82% (29/35) in the amoxicillin-treated group and 98% (39/40) in the erythromycin-sulfa-treated group were cured. Patients with S pneumoniae as the initial infecting organism who were treated with amoxicillin had significantly more clinical recurrences then their erythromycin-sulfa-treated counterparts, 66% (8/12) vs 33% (3/9). There was no difference between treatment groups in recurrence rates for patients with Haemophilus as the initial infecting organism. On the treatment day indicated, the following number of patients had middle ear effusion: by days 10 to 14, 38% (27/72) amoxicillin-treated patients and 48% (35/73) erythromycin-sulfa-treated patients; by day 28, 10% (7/71) amoxicillin-treated patients and 16% (11/70) erythromycin-sulfa-treated patients. There were no significant differences in adverse reactions. The erythromycin-sulfa combination is safe and effective treatment for AOM, including ampicillin-resistant Haemophilus.
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3895890
|
Plasma renin activity (PRA) in neonates is significantly higher than in older infants and children and may increase as a result of numerous physiologic or therapeutic factors. For these reasons, the measurement of PRA is not usually helpful in establishing the cause of hypertension in neonates. In conditions that suppress renin release, however, measurement of PRA can be most useful. Herein, we describe two infants (ages 4 and 5 months, respectively) with sustained hypertension and low PRA secondary to dexamethasone-suppressible hyperaldosteronism. Low PRA was essential in establishing this diagnosis in both patients. Dexamethasone-suppressible hyperaldosteronism should be considered in hypertensive infants who have normal genitalia and low PRA.
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3895891
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Nearly 150 years ago, a seaman received a blow on the right side in the liver region, dying a month later. As a result of fresh autopsy findings, the accused was arrested and imprisoned. However, the defense counsel obtained an exhumation order. This led to the discovery of coexisting lethal disease and culminated in full discharge by a grand jury. The various aspects of the case are examined and shown to anticipate modern principles of expert evidence.
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3895892
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The XIIIth Congress of the International Academy of Forensic and Social Medicine will be held in September 1985, in Budapest, and for this occasion we gave a brief account of the past and present state of forensic medicine in Hungary.
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3895893
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The importance of Dr. Sidney Kaye's contributions in the field of forensic science cannot be over-emphasized. He can be called a pioneer in the field of forensic science and forensic toxicology because of the many contributions he has made to analysis, the literature and poison control, as well as activities in alcohol and drug analysis. He has been fortunate in being a part of history through his relationship, as a student, to Dr. Alexander Gettler, the founder of modern-day forensic toxicology, and by working with Dr. Gradwohl in Saint Louis, Missouri in the 1950s, when the American forensic sciences were being organized. Dr. Kaye is one of the founders of the American Academy of Forensic Sciences, the foremost and largest forensic science organization in the World. It is for these reasons that he received the Alexander O. Gettler Award by the Toxicology Section of the American Academy of Forensic Sciences, for outstanding analytical achievements in forensic toxicology, at the annual meeting of the American Academy of Forensic Sciences, in Las Vegas, Nevada, on February 14, 1985.
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3895896
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The mode of natural transmission of Creutzfeldt-Jakob disease remains unknown. In a case-control study conducted in 1981-1983 to evaluate possible dietary and other sources of the disease, 26 cases were ascertained in the mid-Atlantic region of the United States, 23 of which were obtained from accumulated records of the Laboratory of Central Nervous System Studies of the National Institutes of Health. Controls included 18 family members and 22 hospital-matched individuals (total sample size, 66). An increased consumption among patients was found for roast pork, ham, hot dogs (p less than 0.05), roast lamb, pork chops, smoked pork, and scrapple (p less than 0.1). An excess consumption of rare meat (p less than 0.01) and raw oysters/clams (p less than 0.1) was also reported among the patients. Liver consumption, among organ foods, was greater (p less than 0.1) among the cases. If Creutzfeldt-Jakob disease is acquired through ingestion of foods containing the agent, then the food items identified may be among those which need to be evaluated more intensively. Larger case-control studies with more focused dietary questions are warranted.
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3895898
|
A longitudinal study of 266 adult residents of the Pacific Island of Nauru (1975-1976 and 1982) has shown an annual incidence of noninsulin-dependent diabetes of 1.6 per cent per annum. Factors associated with the subsequent development of glucose intolerance were determined by means of regression techniques. The two-hour, post-load plasma glucose concentration was the factor most consistently associated with subsequent glucose intolerance. Other predictors were found to vary in their importance between the sexes. In males, the fasting plasma triglyceride concentration and blood pressure showed a weaker association, and body mass index was of marginal significance. In contrast, in females, two-hour plasma insulin concentration, plasma uric acid concentration, body mass index, and fasting plasma glucose concentration showed a significant association. These findings are discussed in light of the results of similar studies in other populations.
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3895900
|
A case of XY gonadal dysgenesis with renal failure is presented. Diagnosis was delayed four years post renal transplantation. A uterus, fallopian tubes, and vagina were present with a combined gonadoblastoma and dysgerminoma found in the right streak gonad. Six other similar cases have been reported, including concordance in a pair of monozygous twins. Because of the risk of gonadal malignancy, the serum FSH concentration should be determined in phenotypic females with primary amenorrhea and chronic renal disease. Due to a physiologic reduction in the serum FSH concentration in agonadal individuals between 5 and 11 years of age, a karyotype may be required to detect affected individuals during this interval. Gonadectomy should be performed in all cases of XY gonadal dysgenesis. A urinalysis and serum creatinine concentration should be obtained in girls presenting with XY gonadal dysgenesis. The serum FSH concentration and karyotype should be determined in females presenting with congenital nephrotic syndrome.
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3895901
|
Oliguria has been considered a cardinal feature of acute renal failure. However, many recent reports indicate that acute renal failure usually occurs in the setting of well-maintained urine output. Moreover, the nonoliguric state may accompany acute renal failure due to pre- and post-renal azotemia and a variety of renal parenchymal disorders, as well as acute tubular necrosis. Most studies indicate that nonoliguric forms of acute renal failure are associated with less morbidity and mortality than oliguric acute renal failure. Uncontrolled studies also suggest that volume expansion, potent diuretic agents, and renal vasodilators can convert oliguric to nonoliguric acute tubular necrosis if administered early in the course of acute renal failure. However, prospective studies of early intervention in oliguric patients are needed.
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3895902
|
The adolescent with ESRD is frequently immature in relationship to chronological age. Growth and pubertal development are major concerns for the adolescent with ESRD. If renal failure had its onset prior to adolescence, it is likely that puberty will be delayed and ultimate adult height retarded for the patient requiring ESRD care during the adolescent period. Non-compliance with the therapeutic regimen is a major clinical problem encountered in the management of the adolescent. Significant morbidity can result from non-compliance with the dialysis regimen and non-compliance is a major cause of allograft loss in the adolescent transplant recipient. The special needs of the adolescent must be considered if ESRD care is to be successful.
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3895903
|
Four trials have been conducted by the European Organization for Research and Treatment of Cancer's International Antimicrobial Therapy Project Group. These studies involve the randomized assignment of febrile neutropenic patients to receive various antibiotic combinations. The past three trials have utilized amikacin in combination with a variety of beta-lactam antibiotics to provide activity against the most commonly isolated pathogenic bacteria in this clinical setting. Amikacin in combination with expanded-spectrum beta-lactam agents is likely to remain useful in treating infections in granulocytopenic patients.
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3895904
|
Controversy has developed regarding the antibiotic management of intra-abdominal sepsis because of the recent availability of the third-generation cephalosporins and ureidopenicillins as alternatives to traditional combination therapy (aminoglycosides plus clindamycin). Most observers now acknowledge the need to provide anti-anaerobic as well as anti-aerobic gram-negative drug coverage. Although most of the newer agents do provide such broad-spectrum coverage, doubt remains regarding their efficacy because of flaws in comparative study design and the observation that resistance to the newer agents, which may even extend to the aminoglycosides, can emerge in individual patients during single courses of antibiotic therapy. Indeed, such resistance is most likely to occur during the treatment of seriously ill, immunodepressed patients who have undergone multiple reoperation for persistent or recurrent intra-abdominal sepsis--the precise group for which the new drugs were most desired as less toxic alternatives to the aminoglycosides. On the basis of such observations, combination therapy with the aminoglycosides, appears to remain the most logical choice. In the setting of nosocomial sepsis and pathogen resistance to other aminoglycosides, amikacin may be especially effective. Recent surveillance data indicate that the use of amikacin under such circumstances not only may provide effective antibiotic therapy, but also may actually reduce the level of microbial resistance to the other aminoglycosides. Past concern regarding the development of resistance to amikacin has probably been excessive and should not deter the use of this agent under appropriate clinical circumstances.
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3895907
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Thirty-three renal allograft recipients who had high blood pressure (mean arterial pressure more than 105 mm Hg) at least one year after their successful transplant operation were compared with 23 normotensive kidney transplant recipients (mean arterial pressure less than 105 mm Hg) at the General Clinical Research Center. The patients with higher blood pressure had markedly and significantly higher (96 percent) renal vascular resistance and significantly lower (41 percent) renal plasma flow. Responses to salt loading and restriction were suggestive of marked activity of the renin-angiotensin system as were plasma renin activity measurements. Subsequent follow-up has revealed chronic rejection or renal artery stenosis as a probable cause of hypertension for 11 of the 33 patients. The remaining 22 patients had increased renal vascular resistance and decreased renal plasma flow indistinguishable from that in the 11 patients in whom follow-up revealed a cause for their persistent hypertension; however, 21 of these 22 patients have their native kidneys in place.
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3895906
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To evaluate the variability in the diagnosis of depression in patients receiving maintenance therapy for end-stage renal disease, a study of 60 randomly selected patients was conducted. Three representative depression assessment methods were employed concurrently in the evaluation of each patient: (1) a structured psychiatric interview based on the diagnostic criteria of the American Psychiatric Association (DSM-III); (2) the Beck Depression Inventory; and (3) the Multiple Affect Adjective Check List. Among the 60 patients, 47 percent were classified as depressed by the Beck Depression Inventory, whereas 17 percent and 5 percent were determined to be depressed according to the Multiple Affect Adjective Check List and DSM-III criteria, respectively. The data demonstrated these differences to be dependent on the overlap between the symptoms of uremia and depression, as well as on the duration of those symptoms. This study also suggests that death wish, suicidal intention, and other psychologic symptoms should receive particular attention in the clinical assessment of depression in patients with end-stage renal disease.
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3895910
|
Elevation in the blood level of thyroid-stimulating hormone (thyrotropin) is the earliest and most sensitive manifestation of thyroidal failure, and is detectable in clinically healthy and apparently euthyroid persons. Oral thyroxine supplementation designed to titrate thyrotropin back to normal levels, and readjustment of the supplementary dose as failure of the gland progresses and thyrotropin level rises again, may prevent the emergence of clinical hypothyroidism.
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3895908
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Forty-six renal donors who responded to a questionnaire and two additional donors with nephrotic syndrome and renal insufficiency were studied. The mean age was 46 +/- 2.0 years (mean +/- SE). Duration of follow-up was 6 +/- 0.5 years. Serum creatinine levels increased from 1.0 +/- 0.03 mg/dl before donation to 1.2 +/- 0.04 mg/dl at follow-up. The incidence of proteinuria (more than 150 mg over 24 hours) was 39 percent. The serum creatinine level was 1.0 +/- 0.08 mg/dl and 1.2 +/- 0.06 mg/dl in the proteinuric and nonproteinuric groups, respectively. The incidence of hypertension was 31 percent with a serum creatinine level of 1.1 +/- 0.11 mg/dl and 1.2 +/- 0.07 mg/dl in the hypertensive and normotensive groups, respectively. One patient with nephrotic syndrome had proliferative glomerulonephritis. It is concluded that renal donation is associated with a minimal but statistically significant increment in serum creatinine levels. The incidence of mild hypertension and proteinuria is increased, but impact on renal function is minimal as assessed by serum creatinine determination.
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3895911
|
Fungal osteomyelitis is rare in patients who are not immunocompromised. This report documents that Aspergillus vertebral osteomyelitis may, however, be associated with infection of an adjacent prosthetic vascular graft in the absence of overt immunosuppression. A 73-year-old man is described with a mycotic pseudoaneurysm of a Dacron aortic bypass graft and contiguous vertebral osteomyelitis due to Aspergillus fumigatus. The patient was successfully treated with resection of the infected graft and administration of amphotericin B in a total dose of 2 g. Infection may have occurred intraoperatively as a result of inoculation with airborne fungal elements.
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3895909
|
Both alcohol and exercise have been said to protect against coronary heart disease. The epidemiologic data suggest exercise, per se, does, but alcohol, per se, does not protect against coronary heart disease. Recent longitudinal data suggest teetotalers, especially those who have never smoked, have the lowest coronary heart disease mortality of all. Other cross-sectional and longitudinal studies that suggest light drinkers have the lowest coronary heart disease mortality may be biased because: (1) the teetotalers include some ex-drinkers who may have quit drinking because of coronary heart disease; and (2) the light drinkers include some who drink very rarely, and/or drink very small amounts, and/or have a lower risk of coronary heart disease independent of alcohol because they are more health-conscious in general. The metabolic data also suggest exercise, but not alcohol, protects against coronary heart disease. Exercise increases the level of high-density lipoprotein 2, which correlates well with coronary heart disease risk; alcohol in moderation seems to increase the level of high-density lipoprotein 3, which correlates poorly with coronary heart disease risk and may merely reflect hepatic enzyme induction. Exercise and alcohol influence blood pressure, body weight, and glucose tolerance in opposite directions; in each instance, the influence of exercise is beneficial, that of alcohol detrimental, to the prevention of coronary heart disease. There seems to be no reason to use alcohol for coronary protection.
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3895912
|
Antimicrobial combinations have been widely utilized since the beginning of the chemotherapeutic era. This is true despite the fact that the use of such combinations has a number of potential disadvantages, including (1) antibiotic antagonism; (2) an increased incidence of toxicity; (3) the emergence of multi-resistant organisms; (4) promotion of a false sense of security; and (5) increased expense. The reasons generally given for the use of such combinations include (1) antimicrobial synergism, (2) suppression of antimicrobial resistance, (3) decreased toxicity, and (4) broader coverage. Although there are clearly some situations in which synergistic combinations have been shown to be useful (such as in the treatment of enterococcal endocarditis and severe Pseudomonas infections), the use of combination therapy to reduce the emergence of resistance (excluding the treatment of mycobacterial infections and of infections in which rifampin is used) or to reduce toxicity has not met with widespread success. Indeed, most combinations are used simply to broaden the spectrum of antimicrobial coverage. The development of new penicillins and cephalosporins with broader spectra of activity has raised the distinct possibility that these drugs could be used as single agents for the treatment of most serious infections. Although comparative studies performed to date suggest that the new broad-spectrum penicillins and cephalosporins may be useful as single agents in the treatment of infections in a variety of clinical situations in which combinations are now commonly employed, additional studies enrolling greater numbers of patients are necessary to determine whether these agents can replace combination therapy. The use of single-drug therapy in the management of febrile episodes and documented infections in neutropenic patients remains problematic because of the greater likelihood of infections with organisms such as Pseudomonas aeruginosa, in which case combination therapy is often required. Earlier studies have clearly documented that combinations of antibiotics that are synergistic are more effective in treating bacteremias and other serious infections in neutropenic patients than are combinations that have failed to demonstrate synergism. Because of the increased activity of some of the newer drugs, such as ceftazidime, against P. aeruginosa it is possible that such agents could be used as monotherapy for patients with severe neutropenia. This possibility is an attractive one, but it should be studied carefully to make certain that it will not be associated with significant failure due to the emergence of resistant organisms.
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3895913
|
Overall results from worldwide clinical studies of ceftazidime in open and comparative trials conducted over a four-year period in North America, Europe, and elsewhere are presented. Data from 3,570 patients treated with ceftazidime in open studies and from 1,340 patients receiving ceftazidime and 1,180 patients receiving other antibiotics in comparative studies are discussed. The comparative antibiotics consisted of aminoglycosides alone in 14.2 percent of patients, aminoglycosides combined with one or two beta-lactams in 43 percent, beta-lactams alone in 34 percent, and other antibiotic combinations in 8.8 percent. In comparative studies, bacterial clearance rates were 80.6 percent for ceftazidime and 72.5 percent for other antibiotics. Clinically, 92.6 percent of the infected sites in ceftazidime-treated patients in open studies were cured or improved, and 91.1 percent were cured or improved in comparative studies; 84.8 percent of the infected sites were cured or improved in patients treated with other antibiotics. Data indicate that ceftazidime monotherapy is as effective as combination antibiotic therapy in the empiric treatment of febrile non-neutropenic patients. The role of ceftazidime monotherapy in the treatment of febrile neutropenic patients is not yet firmly established. Superinfections were reported in 2.6 percent of the patients treated with ceftazidime alone in open trials, in 4.2 percent of the patients treated with ceftazidime alone in comparative trials, and in 8.5 percent of the patients treated with other antibiotics. During treatment, the sensitivity of bacteria to ceftazidime decreased in 2.5 percent of the pathogens isolated. Adverse events occurred in 10.2 percent of patients treated with ceftazidime in open studies, in 8.4 percent of those treated with ceftazidime in comparative studies, and in 8.8 percent of those treated with other antibiotics. The adverse events in both ceftazidime- and control-treated patients were thought by the investigators to be drug-related in about 40 percent of cases, not drug-related in 20 percent of cases, and of unknown etiology in the remaining cases.
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3895915
|
There has been remarkable progress in the development of new antimicrobial agents as the result of structural modifications of the cephalosporin nucleus. It has been possible to predict many aspects of the antimicrobial activity of new agents and to recognize the structural modifications that contribute to overcoming the continued problem of bacterial resistance. The activity of beta-lactams against gram-positive species depends primarily on their affinity for the enzymes referred to as penicillin-binding proteins. Resistance of gram-positive species to beta-lactams is either due to altered penicillin-binding proteins or, more commonly, due to the presence of beta-lactamases, which are usually plasmid-mediated and inducible. The activity of beta-lactams against gram-negative aerobic and anaerobic bacteria is the result of the way in which the compounds pass through the porin channels in the outer wall, resist inactivation by beta-lactamases, and bind to the penicillin-binding proteins. The basic cephalosporin nucleus consists of the essential beta-lactam ring fused to a dihydrothiazine ring. It is possible to modify this structure to increase antibacterial activity. Changes in moieties at position 3 affect pharmacologic activity but can also cause a marked increase or decrease in activity against staphylococci and Pseudomonas species. The presence of the thiomethyltetrazole group at position 3 has been associated with an alteration in prothrombin synthesis and with disulfiram reactions. Modifications of the cephem nucleus at position 7 by addition of methoxy groups increase beta-lactamase stability but decrease activity against gram-positive species because of lower affinity for penicillin-binding proteins. The more useful acyl side chains have been those that contain a 2-aminothiazolyl moiety, which causes increased affinity of the molecules for penicillin-binding proteins of gram-negative bacteria and streptococcal species. Iminomethoxy groups provide beta-lactamase stability against the common plasmid beta-lactamases such as those of Staphylococcus aureus and the TEM, SHV-1, OXA, and PSE enzymes found in Enterobacteriaceae and Pseudomonas aeruginosa, as well as the chromosomally mediated K-1 and P99 enzymes of Enterobacter. A propylcarboxy group increases beta-lactamases stability and also provides activity against P. aeruginosa and some Acinetobacter. Conversely, this particular grouping reduces the beta-lactamase induction capabilities of a compound, as well as its ability to function as a beta-lactamase inhibitor.(ABSTRACT TRUNCATED AT 400 WORDS)
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3895917
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The in vitro activity of ceftazidime against Pseudomonas aeruginosa and P. cepacia isolates from patients with cystic fibrosis was compared with that of other antipseudomonal drugs. Ceftazidime was as potent as imipenem against P. aeruginosa and the only drug effective against P. cepacia. An evaluation of the elimination kinetics of ceftazidime in 20 cystic fibrosis patients revealed an elimination half-life of 1.76 hours, an apparent distribution volume of 0.27 liters/kg, and a serum clearance rate of 133.9 ml/minute/1.73m2. Urinary recovery of ceftazidime was 87 percent within the first 24 hours after administration of the drug, with 65 percent recovered in the first two-hour fraction. Probenecid administration had no effect on the elimination kinetics of ceftazidime. Forty-three patients who had either shown no response to conventional therapy or had sputum Pseudomonas isolates that were susceptible only to ceftazidime received 75 courses of therapy. In 67 percent of these patients, the clinical response, when evaluated using an objective clinical efficacy scoring system, was considered favorable. Clinical failures were not associated with the development of drug resistance. Thus, ceftazidime can be recommended for the treatment of acute pulmonary exacerbations in patients with cystic fibrosis.
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3895916
|
Patients with hospital-acquired lower respiratory infections pose both diagnostic and therapeutic challenges. Such infections are commonly seen in critically ill patients. When nosocomial pneumonia is suspected, treatment is generally initiated with broad-spectrum antibiotics before culture results become available. The usual therapeutic regimen includes an aminoglycoside with or without a beta-lactam agent. In a clinical efficacy study of a single agent, ceftazidime, in the treatment of 20 adults with hospital-acquired lower respiratory infection, 18 patients showed clinical improvement with ceftazidime therapy and pathogens were eradicated in 11. Therapeutic failures occurred in two patients who received empiric therapy prior to the isolation of pathogens resistant to ceftazidime. The median minimal inhibitory concentration of ceftazidime for the isolated pathogens was 0.78 micrograms/ml. Of the 15 patients infected with Pseudomonas aeruginosa, 14 showed a favorable clinical response. Therapy-limiting side effects occurred in two patients and bacillary resistance developed in one patient. The efficacy and safety of ceftazidime in the treatment of hospital-acquired pneumonias were comparable to results previously demonstrated for amikacin, cefotaxime, and imipenem in studies conducted at our institution. In studies reported in the literature, 44 of 51 patients (86 percent) with nosocomial pneumonia who were treated with ceftazidime had a favorable clinical response to therapy. The patients included in these studies were neither neutropenic nor commonly bacteremic, and none had cystic fibrosis. Ceftazidime appears to be a useful agent in the treatment of selected patients with nosocomial pneumonias, including those due to P. aeruginosa.
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3895919
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Experience with the use of first-generation cephalosporins in bacterial meningitis has been disappointing; low concentrations were obtained in the cerebrospinal fluid, and therapeutic failures were encountered. Of the second-generation cephalosporins cefamandole, cefuroxime, and cefoxitin, only cefuroxime has proved efficacy in meningitis caused by meningococci, pneumococci, or Hemophilus influenzae. The third-generation cephalosporins offer new advantages in the treatment of meningitis because they are active at the cerebrospinal fluid concentrations obtainable. Cefotaxime has produced high cure rates in patients with meningitis caused by meningococci, pneumococci, or H. influenzae. Several controlled comparative studies indicate that ceftriaxone is as effective as conventional treatment in therapy for neonatal or childhood meningitis caused by Streptococcus agalactiae, Escherichia coli, or H. influenzae. Moxalactam has been found in uncontrolled studies to be effective when the cause was enteric gram-negative bacilli. Ceftazidime is a new cephalosporin with a high degree of beta-lactamase stability and a broad antibacterial spectrum, which includes Pseudomonas aeruginosa that enters the cerebrospinal fluid. Data from 29 patients who received ceftazidime as monotherapy for bacterial meningitis showed an overall cure or improvement rate of 75.9 percent. Therapy failed in three patients with meningitis caused by gram-positive organisms (Staphylococcus aureus, S. epidermidis, S. agalactiae), and in three with gram-negative organisms. Of 14 patients with Pseudomonas meningitis, 11 showed a cure, as did six of six patients with meningitis caused by Enterobacter, Serratia, or Acinetobacter. More, preferably controlled, studies of the efficacy of ceftazidime in the treatment of meningitis should be undertaken.
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3895918
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Ceftazidime, a new beta-lactamase-resistant cephalosporin, was compared with a combination of ampicillin and chloramphenicol for the treatment of meningitis in 100 infants and children aged one month to 15 years. In this open, randomized trial conducted in the Dominican Republic, 61 patients received 50 mg/kg of ceftazidime intravenously every eight hours; 39 received ampicillin plus chloramphenicol in conventional dosages. Seventy-eight of the patients had discernible isolates in samples from cerebrospinal fluid, six had a positive diagnostic Directogen result, and the remainder either had miscellaneous pathogens evident in samples of cerebrospinal fluid, bacteriologic growth in cultures of blood samples only, or no bacteriologic growth in cultures of either cerebrospinal fluid or blood. Among patients with discernible etiologic agents in samples of cerebrospinal fluid, 11 of 57 (19 percent) ceftazidime-treated patients died, and five of 27 (19 percent) patients treated with the combination died. Mortality by pathogen was as follows for patients who received ceftazidime or ampicillin plus chloramphenicol, respectively: Hemophilus influenzae, two of 27 (7 percent) and one of 15 (6 percent); Streptococcus pneumoniae, six of 12 (50 percent) and two of five (40 percent); Neisseria meningitidis, none of 11 (0 percent) and one of six (17 percent); and Salmonella, neither of two (0 percent) and one of one (100 percent). Overall mortality in the ceftazidime group was 20 percent versus 21 percent in the combination group. No significant toxicities were noted in the patients treated with ceftazidime.
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3895921
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The collective experience with ceftazidime in the treatment of skin, soft tissue, bone, and joint infections is presented. Patients were treated with dosages ranging between 25 and 150 mg/kg per day for between five and 42 days. A total of 570 patients with skin and skin structure infections were treated with ceftazidime. Comparative studies, using either cefamandole or tobramycin plus ticarcillin as control drugs, included 239 patients. There were 600 evaluable patients in five categories of skin or skin structure infection: 252 patients had cellulitis, 107 had wound infections, 103 had abscesses, 90 had skin ulcers, and 48 had other miscellaneous infections. Bacteriologic etiologies were gram-negative rods in 303 episodes, gram-positive cocci in 241, anaerobes in 14 episodes, and miscellaneous other organisms in 48 episodes. Overall bacteriologic efficacy was 90 percent in ceftazidime-treated infections and 76 percent in control-treated infections. The clinical efficacy of ceftazidime against infections caused by the gram-positive cocci, particularly Staphylococcus species, was surprisingly good (85 percent) and similar to the efficacy achieved in the cefamandole-treated patients (85 percent). The overall clinical efficacy for ceftazidime was 93 percent. One hundred thirty-four patients with bone or joint infections received ceftazidime. The dosages were similar, but the duration of treatment was the longest in this group. Ceftazidime treatment was compared with standard dosages of tobramycin and ticarcillin in 11 patients. Osteomyelitis was cured in 58 of the 101 patients who received ceftazidime. In five patients, osteomyelitis failed to respond: in two, a resistant Pseudomonas strain emerged; the other three failures were due to persistent bone sequestra. Thirty-eight patients showed improvement. Of those in the tobramycin and ticarcillin group, nine of 10 evaluable patients (90 percent) showed either cure or improvement. The one failure was due to a persistent sequestrum. Thirteen patients with septic arthritis and seven with bursitis were also treated with ceftazidime; the overall cure rate was 75 percent. Adverse reactions to ceftazidime were severe, and the drug was discontinued in 13 of 570 (2.3 percent) patients with skin or skin structure infections and in five of 134 (3.7 percent) patients with bone and joint infections. These data suggest that ceftazidime is effective as monotherapy in the treatment of skin, skin structure, bone, and joint infections, and that it may be more efficacious against staphylococcal infections than predicted from in vitro data.
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3895920
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The distinction between complicated and uncomplicated urinary tract infections is usually based on the presence or absence of some abnormality in the path of urine flow. Other differences include characteristic patient profiles, usual setting, likely pathogens and their antimicrobial susceptibility, and treatment options. Complicated infections are most common in older patients, usually men with prostatic enlargement. Gram-negative bacilli are the most frequent pathogens, but Escherichia coli plays a less dominant role. Isolates from patients with complicated infections are more likely to be resistant to older antibiotics, and therapy is usually parenteral. Many complicated urinary tract infections are hospital-acquired, and are often due to indwelling urinary catheters. Resistance to antimicrobials among isolates is common in this setting. Nosocomial urinary tract infections contribute substantially to morbidity, mortality, and health care costs. Numerous effective treatment options are available for uncomplicated infections. The types of patients, predisposing factors, and organisms limit antimicrobial choices for complicated infections. Although new antibiotics offer certain advantages, final therapeutic success usually depends on resolving the disorder that predisposes the patient to infection.
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3895922
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Infectious complications are a frequent cause of morbidity and, at many centers, the major cause of death in patients with cancer. The increased risk and severity of infectious sequelae result from profound alterations in normal host defenses that occur secondary to the underlying malignancy and the treatment thereof. During the last decade, early empiric antibiotic therapy has become standard practice in the initial management of febrile granulocytopenic patients and has contributed significantly to the improved outcome among patients undergoing cancer therapy. Although early death due to unsuspected or inadequately treated bacterial infection has been largely overcome, new problems--also with life-threatening implications--have emerged. As the use of cancer chemotherapy continues to increase, new populations of patients are being placed at increased risk of infection. Defining the host and environmental factors that contribute to this risk assumes central importance for delineating those patients who require the most intense surveillance. Changing medical practices (e.g., increased use of indwelling catheters) have contributed to the emergence of new pathogens. Recent drug developments (e.g., the third-generation cephalosporins and extended-spectrum penicillins) offer new treatment options, as well as generate controversy and confusion. For example, authorities disagree on the optimal duration and modifications in treatment that are required by cancer patients who remain granulocytopenic and who thus are at continued risk of multiple infectious episodes or superinfections. A question of current interest is whether combination therapy with synergistic agents is important in light of the development of the third-generation cephalosporins and extended-spectrum penicillins. Several of these new antibiotics have an exceedingly broad spectrum of activity that includes Pseudomonas aeruginosa, as well as Enterobacteriaceae, Serratia, Citrobacter, indole-positive Proteus, and anaerobes (including Bacteroides fragilis). However, the third-generation cephalosporins are not as active against staphylococci and streptococci as are the first-generation cephalosporins, and none is effective against enterococci. Nonetheless, these agents achieve serum levels that can be 10 to 100 times greater than the minimal inhibitory and bactericidal concentrations of gram-negative bacteria, raising the possibility that these drugs might be effective as single agents. The advantages of the third-generation cephalosporins are their minimal toxicity and long serum half-lives.(ABSTRACT TRUNCATED AT 400 WORDS)
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3895924
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Ceftazidime has broad antibacterial activity against many gram-positive and most clinically significant nosocomial gram-negative bacillary pathogens. Many studies have been undertaken both in this country and in western Europe to determine the clinical effectiveness of ceftazidime in seriously ill patients. Differentiating between nosocomial and community-acquired infections is difficult in many reports, but high cure rates, usually exceeding 80 percent, have been reported for documented gram-negative bacillary infections. In non-neutropenic patients, response rates have also been in a comparable range. Particularly impressive have been the high cure rates in Pseudomonas aeruginosa bacteremia complicating burns and other gram-negative bacteremias in patients with underlying diseases. In comparative studies carried out in seriously ill or neutropenic patients, the results with ceftazidime have not significantly differed from those obtained with regimens that included beta-lactam agents paired with aminoglycosides. Some problem areas persist in these studies: the interpretation of comparative studies in which a large number of cases were eliminated because of "unevaluability," superinfections due to gram-positive organisms that may require or necessitate addition of agents like vancomycin, and the emergence of resistance as seen in three groups of organisms--Pseudomonas, Serratia, and Enterobacter species. Nonetheless, summary data from cases treated in the United States indicate cure and/or improvement in 100 percent of 14 cases of Serratia bacteremia, 83 percent of 12 cases of Enterobacter sepsis, 82 percent of 22 cases of Staphylococcus aureus bacteremia, and 85 percent in 27 cases of P. aeruginosa bacteremia. Only 11 of 86 cases of bacteremia due to the organisms just cited were judged unevaluable. Three of the four failures in the treatment of Pseudomonas bacteremia occurred in neutropenic patients. More definitive information on the relative efficacy of ceftazidime in controlled trials, particularly in granulocytopenic patients, may result from more careful analysis of survivorship using methods that do not eliminate "unevaluable cases." Techniques for this type of analysis have already been implemented in some studies.
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3895923
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The initial therapy of febrile neutropenic cancer patients is an evolving, interesting, and important area of medical research. The introduction of carbenicillin provided the clinician with an antibiotic that had significant activity against Pseudomonas aeruginosa. Prior to the availability of this drug, neutropenic patients with bacteremia due to this organism did no better with antibiotic therapy than without it. Since then, several agents including carboxy- and ureidopenicillins, aminoglycosides, cephalosporins, monobactams, and carbapenems have appeared on the scene and strengthened our therapeutic armamentarium. Since some of them have an expanded spectrum of activity, they have been widely utilized for combination therapy. More recently, several clinical trials have addressed the feasibility of using them alone as initial empiric therapy in these patients. Some of the studies have achieved good results, especially when treating gram-negative infections, although these results should be interpreted with caution, since the studies were usually conducted under controlled conditions. These trials have, however, not been as successful when treating gram-positive organisms, which have again become an important cause of infection in these patients; in some of them, a specific antibiotic against these organisms had to be added. How will this approach utilizing newer antibiotics compare against a more conventional regimen of two synergistic agents? Hopefully, this will be better investigated and defined in the near future.
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3895926
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We describe two sibs affected with Jeune syndrome. The first was diagnosed after birth and the second was diagnosed prenatally using ultrasonography. The detected abnormalities were confirmed by X-ray and autopsy following pregnancy termination. This observation indicates the possibility of prenatal diagnosis of the condition.
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3895927
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A fetus with Weyers oligodactyly was studied after a previous sibling had been born with that condition. Prenatal diagnosis was undertaken using ultrasound to visualize the long bones, which were found to be severely affected by the condition at 19 weeks of gestation. Most notable were the ulnae and fibulae, which were very short; the fetus had bilateral hydronephrosis.
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3895928
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We describe a method for the morphological, developmental, and functional analysis of the fetal spine. Using this system, different types of spina bifida and hemivertebrae have been discovered. A system of quality control and documentation is proposed and cases that were not detected ultrasonographically are described. The results of the analyses of seven abnormal fetuses out of 818 pregnancies examined by us and three referred after birth are presented, including fetuses with caudal regression, spina bifida, hemivertebrae with lordosis and kyphosis, and spina bifida without ultrasonographic or radiologic evidence of bone abnormality. Cases that were not diagnosed ultrasonographically by other observers are presented.
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3895929
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After an introduction dealing with the "historical evolution" of the Noonan syndrome (NS), we try to define the NS phenotype based on clinical descriptions published since 1883. The theories concerning the cause of the NS are discussed fully. The peculiar cardiac involvement deserves special attention and raises the question of whether the Watson and LEOPARD syndromes are indistinguishable from NS. Finally, the recent contributions to the variability of the NS phenotype (reports on lymphatic dysplasia, partial deficiency of factor XI, malignant hyperthermia, perceptual-motor disabilities, and endocrine evaluation) are also described.
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3895932
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We report on nine individuals with the Pena-Shokeir syndrome. Clinical findings are compared with data on patients from the literature. Emphasis is made on genetic background, neuropathological findings, and (in two cases) on prenatal data. Possible pathogenetic mechanisms are discussed.
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3895931
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We report on a 2-yr-old boy with progressive muscular weakness and respiratory failure. There was no clinical evidence of heart muscle involvement. Autopsy showed marked intralysosomal glycogen deposition in skeletal muscle and liver with no histological evidence of glycogen deposition in cardiac muscle. The activity of the lysosomal enzyme alpha-1,4-glucosidase was deficient in skin fibroblasts, skeletal muscle, cardiac muscle, and liver; however, the enzymatic activity in peripheral blood leukocytes was in the low normal range. The child's mother had normal enzymatic activity in leukocytes but heterozygote levels in skin fibroblasts.
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3895936
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Concurrent abortion and sterilization are preferred by many women to avoid a second hospitalization, operation, and, in some instances, general anesthesia. Several authors have shown concern, however, that the two procedures carry a higher risk of morbidity when performed concurrently versus separately. To determine whether the concurrent performance of sterilization and induced abortion is as safe as the two procedures performed separately, we selected women undergoing these procedures from two separate multicenter, prospective, national United States studies: the Joint Program for the Study of Abortion and the Collaborative Review of Sterilization. Using standard definitions of major morbidity, we calculated the crude rate of one or more major complications to be 0.9% for the abortion-only group, 1.7% for the group concurrent abortion and tubal sterilization. Thus our data suggest that performing concurrent abortion and sterilization is as safe as performing those procedures separately.
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3895937
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Eight hundred twenty-five ambulatory women with a clinical diagnosis of salpingitis were randomized to a 10-day course of either penicillin/ampicillin or tetracycline. Forty-four percent of women had gonococcal salpingitis and 56% nongonococcal salpingitis. Overall, both regimens cured equal proportions of women: At 30 days, 81% were cured by penicillin/ampicillin and 82% by tetracycline. However, the proportion of women with gonococcal salpingitis cured by 30 days was significantly greater than that of women with nongonococcal salpingitis. By 30 days, 14% of women with gonococcal salpingitis and 21% of women with nongonococcal salpingitis were not cured by either regimen. These data suggest that both regimens were only marginally acceptable for women with gonococcal salpingitis and that neither regimen was acceptable for nongonococcal salpingitis.
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3895939
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Mothers with known or occult rheumatic disorders may be delivered of infants with congenital complete heart block. The more frequent use of ultrasonography during pregnancy now allows early detection of heart block in utero. The transplacental passage of SSA or SSB antibodies, of the IgG class, may mediate or be associated with immune damage to the fetal cardiac conduction system, as reported in our two patients. Maternal and/or newborn screening for SSA and SSB antibodies in selected patients permits an early presumptive diagnosis and will assist perinatal planning, particularly for immediate newborn cardiac pacemaker implantation. Early serologic detection of such antibodies may also assist family counseling of mothers at risk and should promote investigation of techniques to modify the immune status of these mothers. SSA- or SSB-positive maternal/fetal pairs should be prospectively managed by the obstetrician, neonatologist, and rheumatologist.
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3895940
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We describe a patient who had abnormal sonographic findings of the liver 24 hours before signs and symptoms of severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). The abnormal sonographic appearance of the liver prompted further investigation and was instrumental in the management of this case.
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3895941
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The etiology of fetal death may be difficult to identify, particularly with the presence of marked fetal maceration and autolysis. Immunofluorescence with human antitreponemal antibody was used in this case to establish a diagnosis of congenital syphilis.
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3895942
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The distribution of fibronectin, a major extracellular glycoprotein with various activities that affect the proliferation and differentiation of cells, was studied by immunofluorescence staining in first-, second- and third-trimester placentas from normal human pregnancy. In early chorionic villi, fibronectin was localized mainly in the trophoblastic basement membranes; this fluorescence became weaker after 10 weeks' gestation. In term placenta, fibronectin was densely deposited around the fetal vessels but not in the trophoblastic basement membranes. Both syncytiotrophoblasts and cytotrophoblasts of the villous epithelium were virtually negative throughout pregnancy. However, the pericellular matrices of nonvillous trophoblasts in early chorionic villi were strongly stained. These findings suggest that fibronectin plays an important role in the proliferation of trophoblastic cells and the tissue organization of the placenta.
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3895946
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Observational study designs used to investigate the relationship of oral contraceptive use to the occurrence of venous thromboembolism, stroke, myocardial infarction, and cardiovascular death include case-control, cohort, and mortality statistics studies. This analysis catalogs the findings of each of these epidemiologic studies, its statistical significance, and its performance with regard to scientific methodologic standards. An association between current oral contraceptive use and incidence of venous thromboembolism without predisposition has been consistently observed in case-control and cohort studies. Associations are less consistent for various types of stroke and for myocardial infarction. Only the Royal College of General Practitioners study found a significantly elevated risk of cardiovascular death with oral contraceptive use. The majority of mortality statistics studies offer little support for a relationship between oral contraceptive use and cardiovascular events. Major systematic problems in the epidemiologic studies include potential for bias in the detection of cardiovascular events and differences in the prognostic susceptibility of compared groups. Bias in the ascertainment of drug exposure is an unresolved issue for most of the case-control studies. Because of possible biases arising from methodologic deficiencies in these epidemiologic studies, questions as to the validity of the observed associations between oral contraceptive use and cardiovascular events should remain.
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3895947
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The clinical efficacy of moxalactam versus clindamycin/tobramycin was evaluated in a comparative, randomized, prospective study. Sixty patients were treated: 30 with moxalactam and 30 with clindamycin/tobramycin. There were 15 cases of tuboovarian abscess, 36 cases of severe pelvic inflammatory disease with peritonitis, eight cases of endomyometritis, and one wound abscess. Aerobic and anaerobic cultures from the sites of infection yielded 441 microorganisms from 53 patients; an average of 8.3 bacteria per infection (4.5 anaerobes and 3.8 aerobes). The infections tended to be mixed aerobic-anaerobic with anaerobes isolated in 90% of cases. The most frequently isolated possible pathogens were Bacteroides sp. (37), Bacteroides bivius (23), Bacteroides asaccharolyticus (12), Peptococcus asaccharolyticus (29), Peptostreptococcus anaerobius (19), unidentified anaerobic gram-positive cocci (18), Escherichia coli (17), nonhemolytic streptococci (16), Neisseria gonorrhoeae (13), and Gardnerella vaginalis (38). Clinical cure was noted in 29 of 30 moxalactam-treated and 29 of 30 clindamycin/tobramycin-treated patients. Moxalactam was effective in five of six cases of tuboovarian abscess, all 22 cases of pelvic inflammatory disease with peritonitis, the one case of endomyometritis and the one wound abscess. Clindamycin/tobramycin was effective in eight of nine cases of tuboovarian abscess, all 14 cases of pelvic inflammatory disease with peritonitis, and all seven cases of endomyometritis. No adverse hematologic, renal, or hepatic effects were noted with either regimen.
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3895948
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A double-blind, placebo-controlled trial was performed to assess the value of cefoxitin for prophylaxis against postoperative infection following radical hysterectomy. Infectious morbidity was observed in 35% of 43 patients in the control group and 23% of 31 in the cefoxitin group. In seven control patients (16%) and one patient (3%) in the cefoxitin group the infections were related to the surgical site (p = 0.07). These differences did not achieve statistical significance. Examination of the data revealed a number of other factors, including operating time, patient weight, blood loss, and blood replacement, that were significantly related to the incidence of infectious morbidity. Comparison of the results of the present study with those in the literature indicates that a careful examination of the circumstances prevailing in any particular institution is necessary before a decision is made on strategies to combat infectious morbidity after radical hysterectomy.
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3895949
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In this report the predictive value of ultrasonic targeted imaging for fetal anomalies (TIFFA) is defined. Six hundred fifteen pregnant women at high risk for birth defects were scanned from January, 1980, to December, 1983. Follow-up evaluation was available on 569 fetuses. The pregnancies were classified into five groups according to the indications used for ultrasonic targeted imaging studies. The largest number of women were placed in group 1 and were referred because of a variety of abnormalities in previous or ongoing pregnancies. The women classified in the other four groups were examined because of maternal or fetal reasons related to specific craniospinal (29%), urinary (7.9%), gastrointestinal (6.7%), and skeletal (3.7%) defects. In our series the predictive values of abnormal and normal ultrasonic targeted imaging studies were 95% and 99%, respectively. A detailed breakdown of the accuracy of ultrasonic targeted imaging in relation to each anatomic category is presented; these data are useful in counseling gravid women with anomalous fetuses.
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3895950
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Behavioral states in the near-term human fetus have been described during pregnancy. The aim of this study was to observe whether these same states are present during labor. Nine patients with uncomplicated singleton pregnancies participated. Fetal heart rate and uterine contractions were recorded. Fetal eye, mouth, rotation, and retroflexion of the head were observed by real-time ultrasound. Fetal movements were recorded with coded event-markers. Behavioral states were identified by the movement pattern. A total of 13 ultrasound observations, varying from 25 to 66 minutes, were obtained. Optimal viewing was present at least 60% and on the average 80% of the time. State 1F (quiet sleep), state 2F (active sleep), and state 3F (quite awake), as well as a total of 10 state changes, were identified during labor in spite of increasing contractions and/or ruptured membranes. These observations demonstrate existence of alternating behavioral states in the healthy term fetus during labor.
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3895951
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The prenatal ultrasonographic diagnosis of conjoined twins in the first trimester is described. The ultrasonographic criteria are discussed together with implications for management.
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3895952
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Fetal weight was estimated sonographically within 3 days of delivery in 103 cases. A stepwise regression analysis was performed to evaluate fetal sex, biparietal diameter, head circumference, abdominal circumference, and femur length as factors in estimation of fetal weight. A new formula for calculating fetal weight was derived. Fetal sex did not affect the results obtained. Incorporation of femur length improved the reliability of the weight estimate. Because of intrapopulation and interpopulation differences, institutions using obstetric ultrasound examination techniques should establish their own formulas for estimating fetal weight.
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3895953
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Presence of immunoglobulin G antibody against the five standard serotypes of group B streptococcus was measured by means of indirect immunofluorescence in the sera of 405 women at the time of delivery in the obstetric hospital in Vancouver. Antibody to all five serotypes was present in 22% of women whereas only 9.6% had no detectable antibody to any serotype. Among 47 women with group B streptococcus vaginal colonization, IgG antibody was detected against the homologous colonizing serotype in 100%, 75%, 78%, 89%, and 100% of sera for serotypes Ia, Ib, Ic, II, and III, respectively. This contrasted with the women who had heterologous group B streptococcal vaginal colonization or no colonization in whom 71% had serum IgG antibody to serotype Ia, 36% to Ib, 51% to Ic, 66% to II, and 60% to III. Overall the serum antibody titers were low, and few women had titers greater than 1:20 for any of the five standard serotypes.
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3895954
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A baseline model for consideration of the theoretical effects of amniotic fluid volume changes on surfactant concentration measurements has been constructed. The baseline data include: a polynomial equation that best fits experimental data comparing amniotic fluid lecithin concentration measurements to gestational age, inflow of 0.450 L of surfactant-poor fluid into the amniotic fluid per day, outflow of 0.450 L of surfactant-rich fluid per day, and volume of 1.0 L of amniotic fluid between 30 to 31 and 38 to 39 weeks' gestation. With this model the incremental amounts of lecithin necessary to achieve the concentration levels derived from the polynomial equation have been calculated. The quantity of lecithin needed was calculated at intervals of 0.1 day for 56 days. Polyhydramnios and oligohydramnios were then allowed to develop hypothetically by modifying the inflow or outflow of fluid while keeping the quantity of lecithin added exactly the same as was determined from the baseline data. Chronic polyhydramnios or oligohydramnios had minimal effects on the concentration measurements. The effects of acute polyhydramnios (or oligohydramnios) were greater when the change in volume was due to an increased (or decreased) volume of inflow as compared to a decreased (or increased) volume of outflow.
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3895955
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Described is a pregnancy complicated by pregnancy-induced hypertension, polyhydramnios, and obstructive renal failure due to an overdistended uterus. A review of the literature disclosed that only five such cases have been reported previously. Fetal outcome was generally related to the duration of gestation at the onset of polyhydramnios.
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