Use of a tantalum-178 generator and a multiwire gamma camera to study the effect of the Mueller maneuver on left ventricular performance: comparison to hemodynamics and single photon emission computed tomography perfusion patterns

During the Mueller maneuver, there is a decrease in intrathoracic pressure and an increase in transmural left ventricular pressure. The changes in loading conditions cause transient left ventricular dysfunction. This study examined the effects of the Mueller maneuver on left ventricular performance using tantalum (Ta)-178 (half-life 9.3 min) and a multiwire gamma camera. First-pass radionuclide angiograms were obtained at baseline and during Mueller maneuver in 41 patients aged 58 +/- 10 years. In 34 patients, stress single photon emission computed tomography (SPECT) myocardial perfusion imaging with thallium-201 or sestamibi was also performed. Hemodynamic measurements during the Mueller maneuver (n = 10) showed a decrease in systemic pressure (139 +/- 25 mm Hg vs 123 +/- 24 mm Hg, p < 0.001) and pulmonary artery pressure (24 +/- 6 mm Hg vs 14 +/- 12 mm Hg, p = 0.01) and an increase in heart rate (67 +/- 10 bpm vs 75 +/- 14 beats/min, p = 0.001). Among the 34 patients who had perfusion imaging, the left ventricular ejection fraction remained unchanged or increased in 17 patients (group 1) (48% +/- 19% vs 49% +/- 21%, p not significant) and decreased (> or = 5%) in 17 patients (group 2) (55% +/- 13% vs 40% +/- 16%, p = 0.001). The stress SPECT images showed no or only fixed defects in 11 (65%) patients in group 1 and 3 (18%) patients in group 2 (p = 0.02), and reversible defects in 6 (35%) patients in group 1 and 14 (82%) patients in group 2 (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Reciprocal inhibition between wrist flexors and extensors in man: a new set of interneurones?

1. Interneurones mediating reciprocal inhibition between wrist flexors and extensors in man are characterized using both Renshaw cells and transarticular group I afferent activation. 2. Renshaw cells were activated by reflex discharges evoked by a tendon tap. The tendon tap was applied to the tendon of the muscles from which the Ia fibres responsible for the reciprocal inhibition originated. Contrary to what was observed both in the cat hindlimb and in human elbow muscles, this Renshaw cell activation never resulted in a long depression of the reciprocal inhibition between wrist flexors and extensors. 3. Convergence from group I elbow muscle afferents and antagonistic group I afferents onto interneurones mediating reciprocal inhibition between wrist muscles was revealed in post-stimulus time histogram (PSTH) experiments using the technique of spatial facilitation. 4. The characteristics of the interneurones mediating reciprocal inhibition between wrist flexors and extensors could therefore be summarized as follows: (a) they are fed by antagonistic group I afferents and group I afferents originating from both flexor and extensor elbow muscles; (b) they are not inhibited by Renshaw cells; (c) they are not excited by low threshold cutaneous afferents; and (d) they are probably interposed in a disynaptic pathway. 5. It is therefore concluded that interneurones mediating reciprocal inhibition between wrist flexors and extensors in man differ both from Ia interneurones and from interneurones interposed in the Ib reflex pathways and these characteristics are related to the complex circumduction movements developed in the wrist.

Exposure with response prevention treatment of anorexia nervosa-bulimic subtype and bulimia nervosa

Binge exposure with response-prevention of bingeing (ERP-B) was evaluated in 20 female Ss within an inpatient eating disorders unit over 9 sessions as an adjunct to standard milieu therapy. Subjects met DSM-III-R criteria for either bulimia nervosa (BN) (n = 13) or the bulimic subtype of anorexia nervosa (AN-B) (n = 7). The average age of the Ss in each group was 26.5 (+/- 8.8) and 24.1 +/- 6.0) yr, respectively. Results indicate significant within-session and pre-post treatment effects in self-report measures 'urge to binge', 'lack of control', 'feelings of guilt' and 'tension'. Further analysis revealed that the AN-B subgroup had significantly greater reduction in 'depression' and 'urge to vomit' compared to the BN group. This study provides preliminary evidence that ERP-B deserves further investigation with long-term follow-up in both BN and AN-B patients and may be particularly advantageous in the AN-B subpopulation.

Chromosome 17 numerical abnormalities in 55 patients with non-Hodgkin's lymphoma: a fluorescence in situ hybridization study

Monosomy 17 and structural abnormalities of the short arm of chromosome 17 have been reported to influence prognosis and treatment outcome in patients with non-Hodgkin's lymphoma (NHL). In diffuse large cell lymphoma, these abnormalities were associated with refractoriness to chemotherapy, higher proliferative rate and poor prognosis. We studied the incidence of chromosome 17 abnormalities in 55 patients with NHL by using fluorescence in situ hybridization with a directly conjugated centromeric probe for chromosome 17. Twenty-three patients (42%) were previously untreated. Thirty-four patients (62%) had diffuse large cell lymphoma, 18 (33%) had follicular low-grade lymphoma, one had small lymphocytic lymphoma, one had diffuse mixed cell lymphoma, and one had mantle cell lymphoma. Cells from benign lymphoid hyperplasia were used as controls. Eight patients (15%) had trisomy 17 in 1.2-40.7% of cells and one patient (1.8%) had monosomy 17 in 68.8% of cells. We conclude that monosomy 17 is not common in NHL. Chromosome 17 deletions should be investigated with region-specific probes to determine their clinical relevance in NHL.

Chromosome X numerical abnormalities in patients with non-Hodgkin's lymphoma. A study of 59 patients using fluorescence in situ hybridization

Chromosome X numerical abnormalities are frequently observed in non-Hodgkin's lymphoma (NHL), with an incidence of 3% to 14% for chromosomal loss and 7% to 33% for chromosomal gain. Because sex chromosome numerical abnormalities are thought to be due to aging, little information is known about their relation to gender, therapy, and prognosis. Therefore, to determine the incidence and clinical relevance of this abnormality in NHL, we studied specimens from 59 NHL patients (31 men and 28 women) by fluorescence in situ hybridization (FISH) using a directly conjugated centromeric probe for chromosome X. The median age for the entire group was 52 years (range, 31-88 years). All specimens were obtained by fine-needle aspiration of diseased lymph nodes. Sex-matched lymphocytes from benign hyperplastic lymph nodes were used as controls. The overall incidence of chromosome X numerical abnormalities was 49.2%. Female patients had a higher overall incidence than males (76% vs. 24%; p < 0.001). The median percentage of cells involved in this abnormality in each specimen was 5.2%. There was no statistically significant difference in the incidence in previously treated than untreated patients (53.1% vs. 44.4%; p < 0.75) and in intermediate-grade NHL than low-grade NHL (61.1% vs. 50%; p < 0.75). There was a trend towards a higher incidence of chromosome X loss in older patients. While the difference in the incidence of chromosome X abnormalities observed between women and men may be due to the difference in the normal copy numbers of this chromosome in each sex group, this abnormality remained higher than any other autosomal chromosome abnormality in NHL previously evaluated by FISH. We conclude that, although FISH detected a high incidence of chromosome X numerical abnormalities and that females had a higher incidence than males, only a small percentage of the cells were involved, suggesting that this abnormality is most likely a secondary genetic defect that is not important in the pathogenesis of NHL.

Assessment of personality disorders in anorexia nervosa and bulimia nervosa. A comparison of self-report and structured interview methods

Interest in assessing Personality Disorders (PDs) in association with anorexia nervosa (AN) and bulimia nervosa (BN) has been accompanied by the development of several structured interview and self-report measures. In an attempt to see how the self-report Millon Clinical Multiaxial Inventory (MCMI-II) compared with the Structured Clinical Interview for DSM-III-R (SCID-II) in the assessment of PDs, we gave both instruments to 43 inpatients with a diagnosis of AN or BN. Correlation coefficient values for both categorical and dimensional comparisons were generally less than .4. Although comparable rates of positive PDs occurred for each of the three clusters (A: 30.2% vs. 34.9%, B: 25.6% vs. 18.6%, and C: 62.8% vs. 81.4% for SCID-II vs. MCMI-II), agreement for individual diagnosis and individual subjects was poor. In conclusion, the MCMI-II did not prove to be a reliable instrument for assessing axis II PDs in patients with AN and BN when compared with the SCID-II.

CT of minor intubation trauma with clinical correlations

Even when performed by an experienced physician, endotracheal intubation is more traumatic than previously supposed. Following emergency intubation, patients have little probability of having a normal larynx. One-hundred patients underwent CT scan of the larynx 6 months or more following endotracheal intubation of short duration (up to 8 h). Ten patients (Group 1) with respiratory arrest underwent emergency intubation; 90 surgical patients (Group 2) underwent anesthesia with endotracheal intubation. Indirect laryngoscopy was performed in 59 symptomatic patients. Abnormal CT findings were present in 86 out of 100 patients. CT irregularities, which included tears, scars and small laryngoceles, were noted on indirect laryngoscopy in 59 symptomatic patients. The laryngeal damage following endotracheal intubation is surprisingly high.

Definition of the best prediction criteria of the time domain signal-averaged electrocardiogram for serious arrhythmic events in the postinfarction period. The Cardiac Arrhythmia Suppression Trial/Signal-Averaged Electrocardiogram (CAST/SAECG) Substudy Investigators

OBJECTIVES

The goal of this study was to establish guidelines for the prognostic use of the time domain signal-averaged electrocardiogram (ECG) after myocardial infarction.

BACKGROUND

Previous studies of the prognostic use of the signal-averaged ECG in postinfarction patients had one or more of the following limitations: a small study group, empiric definition of an abnormal recording and possible bias in the selection of high risk groups or classification of arrhythmic events, or both. To correct for these limitations, a substudy was conducted in conjunction with the Cardiac Arrhythmia Suppression Trial (CAST).

METHODS

Ten centers recruited 1,211 patients with acute myocardial infarction without application of the ejection fraction or Holter criteria restrictions of the main CAST protocol. Several clinical variables, ventricular arrhythmias on the Holter recording, ejection fraction and six signal-averaged ECG variables were analyzed. Patients with bundle branch block were excluded from the analysis, and the remaining 1,158 were followed for up to 1 year after infarction. The classification of arrhythmic events was reviewed independently by the CAST Events Committee.

RESULTS

During an average (+/- SD) follow-up of 10.3 +/- 3.2 months, 45 patients had a serious arrhythmic event (nonfatal ventricular tachycardia or sudden cardiac arrhythmic death). A Cox regression analysis with only the six signal-averaged ECG variables indicated that the filtered QRS duration at 40 Hz > or = 120 ms (QRSD-40 Hz) at a cutpoint > or = 120 ms was the most predictive criterion of arrhythmic events. In a regression analysis that included all clinical, Holter and ejection fraction variables, a QRSD-40 Hz > or = 120 ms was the most significant predictor (p < 0.0001). The positive, negative and total predictive accuracy and odds ratio for QRSD-40 Hz > or = 120 ms were 17%, 98%, 88% and 8.4, respectively, and improved to 32%, 97%, 94% and 16.7, respectively, after combination with ejection fraction < or = 40% and complex ventricular arrhythmias on the Holter recording.

CONCLUSIONS

The signal-averaged ECG predicts serious arrhythmic events in the first year after infarction better than do clinical, ejection fraction and ventricular arrhythmia variables, and QRSD-40 Hz > or = 120 ms provides the best predictive criterion in this clinical setting.

Chronic obstructive pulmonary disease in patients undergoing coronary artery bypass grafting

The purpose of this study was to evaluate the effect of chronic obstructive pulmonary disease on patients undergoing coronary artery bypass grafting. Between June 1991 and June 1993, 651 patients underwent coronary artery bypass grafting: 37 patients (group I) had significant chronic obstructive pulmonary disease. These patients were compared with 37 matched control subjects (group II). Comparison of the groups was made with regard to postoperative morbidity and mortality. Quality of life of survivors was compared at the last follow-up. More patients in group I had preoperative arrhythmias (8 versus 1, p = 0.014). Group I patients had lower values of forced expiratory volume in 1 second (1.366 +/- 0.032 L versus 2.335 +/- 0.49 L, p < 0.0001), lower oxygen tension (63.5 +/- 8.2 versus 79.1 +/- 13.4 mm Hg, p = 0.001), and higher carbon dioxide tension (44.8 +/- 6.5 mm Hg versus 39.7 +/- 3.6 mm Hg, p = 0.001). After operation patients in group I had a longer hospital stay (8.1 +/- 3.6 days versus 6.6 +/- 1.7 days, p = 0.0236) and longer intensive care unit stay (2.64 +/- 0.9 days versus 1.23 +/- 0.49 days, p = 0.0001). More patients in group I required prolonged intubation (7 versus 1, p = 0.0278) and reintubation (5 versus 1, p = 0.088). More patients in group I had significant arrhythmias (27 versus 9, p < 0.0001). During a 16-month follow-up period, five patients in group I died, whereas none in group II died (p = 0.0271). Four deaths were related to arrhythmias. More group I patients were not functionally improved by the operation (17 versus 3, p = 0.0056). The results of coronary artery bypass grafting in patients with significant chronic obstructive pulmonary disease were not favorable in midterm follow-up. A major cause for morbidity and mortality was postoperative arrhythmias.

Changes in reciprocal and transjoint inhibition induced by muscle fatigue in man

The effects of localised muscle fatigue on group I reflex pathways were studied in the human upper limb. Activation of group I afferents originating from biceps and extensor carpi radialis (ECR) resulted in an inhibition of flexor carpi radialis (FCR) motoneurones, probably through a disynaptic pathway. Reciprocal inhibition (from ECR to FCR) and transjoint inhibition (from biceps to FCR) were compared before and during localised fatigue induced in the muscle from which group I afferents originated. Fatigue of wrist extensors did not modify the reciprocal inhibition, while during fatigue of elbow flexors the transjoint inhibition was less pronounced. This striking difference between reciprocal and transjoint inhibition is discussed in relation to the pattern of diffusion of voluntary contractions during fatigue in the human upper limb.

Syringomyelia of the distal spinal cord in children

The syndrome of syringomyelia in children has been extensively described in the literature and is said to most commonly involve the cervical and thoracic spinal cord. We here present two children who had an unusual constellation of signs and symptoms, characterized by bowel and bladder disturbance in one, and in the other with intermittent paroxysmal severe pain and cramping and flexion of the lower extremities accompanied at times by episodes of incontinence. Both were found on magnetic resonance imaging (MRI) to have a syrinx localized to the most distal cord. This was not associated with Arnold-Chiari malformation, trauma, tumors or any other form of spinal dysraphism. Both patients underwent placement of a syringomyelia-peritoneal shunt with complete resolution of symptomatology. Postoperative MRI revealed a complete collapse of the syringomyelia cavity. In those children presenting with bowel or bladder disturbances, associated or not with intermittent pain, flexion attacks, or cramping in the lower extremities, the differential diagnosis of a syringomyelia of the distal cord should be part of the clinical considerations.

The East York Health Needs Study. I: Prevalence of DSM-III-R psychiatric disorder in a sample of Canadian women

BACKGROUND

This study reports the prevalence of psychiatric disorder in women from a Canadian community. The GHQ and the CES-D were compared for their utility.

METHOD

A thousand women over the age of 18 were mailed the GHQ and the CES-D. Our return rate was 44.4%; 24% were personally interviewed by interviews blind to screening information. The CIDI was used to establish DSM-III-R diagnoses. Four versions of the GHQ and one version of the CES-D were calibrated against the CIDI.

RESULTS

The prevalence of general psychiatric disorder was estimated as between 15% and 19%, anxiety disorders between 10% and 13%, and depression occurring with anxiety between 3% and 4%. The calibrated GHQ was the most reliable instrument.

CONCLUSIONS

Prevalence of DSM-III-R psychiatric disorder can be reliably determined with the calibrated GHQ. Anxiety disorders are most prevalent in this community, and were best detected using calibrated versions of the longer form GHQ.

CT evaluation of otorrhagia associated with condylar fractures

To assess a simplified CT evaluation of otorrhagia due to condylar fracture, 16 patients with post-traumatic otorrhagia underwent axial CT of the petrous bones and coronal CT of the temporo-mandibular joints (TMJs). Bilateral high condylar fractures were demonstrated in seven patients. Unilateral subcondylar fracture dislocations with contralateral high condylar fractures were demonstrated in the other nine patients. The otorrhagia was always ipsilateral to a high condylar fracture. Otorrhagia due to condylar fractures occurred when the fracture was bilateral and ipsilateral to a high condylar fracture. The diagnostic procedure of choice is coronal CT of the TMJs which should be carried out if axial CT of the petrous bones showed them to be intact.

Survey of cellular radiosensitivity parameters

A model of the formation of particle tracks in emulsion has been extended through the use of biological target theory to formulate a theory of the response of biological cells and molecules of biological importance to irradiation with energetic heavy ions. For this purpose the response to gamma rays is represented by the single-hit, multitarget model with parameters m and D0, while additional parameters kappa (or a0) and sigma 0 are required to represent the size of internal cellular targets and the effective cross-sectional area of the cell nucleus, respectively, for heavy-ion bombardments. For one-or-more-hit detectors, only the first three of these parameters are required and m = 1. For cells m is typically 2 or more. The model is developed from the concept that response to secondary electrons follows the same functional form for gamma rays and for the gamma rays surrounding an ion's path. Originally applied to dry enzymes and viruses in 1967, the model of the one-hit detector has been extended to emulsions, to other physical and chemical detectors, to single- and double-strand breaks in DNA in EO buffer and to three E. coli strains. The two-hit response has been observed for "track core" effects in radiation chemistry, for supralinearity in thermoluminescent dosimeters and for desensitized nuclear emulsions, where hit numbers up to 6 have been observed. In its extension to biological cells, additional concepts are required relating to the character of the track, namely the grain-count and track-width regimes, and to the ability of multitarget systems to acquire damage from intertrack delta rays (called gamma kill) as well as from intratrack delta rays (called ion kill). The model has been applied to some 40 sets of radiobiological data obtained from gamma, track-segment heavy-ion and neutron irradiations. Here we elaborate on the meaning of these concepts, tabulate the cellular parameters, and display their systematic behavior and the relationships among them. In particular the parameter kappa, which serves to determine the location in Z*2/beta 2 of the maximum value of the RBE, shows little variation among cell types, while D0, which describes the response to gamma rays and sigma 0, which appears to indicate the target size, varies over many orders of magnitude.

The disappearing kidney. A case of emphysematous pyelonephritis

We describe a case of bilateral emphysematous pyelonephritis in which the left kidney could not be visualized sonographically because of multiple irregular air-fluid interfaces. This observation, which to our knowledge has been noted only once before in the literature, may be a diagnostic clue to this potentially fatal disease.

[Long term follow-up of patients with chronic hepatitis due to hepatitis C virus]

Thirty two patients (18 males whose ages ranged from 32 to 68 years old) with hepatitis C virus chronic hepatitis (positive anti-HCV by ELISA, confirmed by RIBA II) that were followed by the authors during 2 to 25 years, were retrospectively analyzed. Thirteen subjects had a history of blood transfusions, one had an accidental pinprick and other a sexual contact with a HCV positive individual; the transmission source was not identified in the resting 19 subjects. Only five individuals had an acute onset. The rest of the patients had few symptoms with moderate and fluctuating transaminase elevations. Liver biopsy at the onset showed a chronic hepatitis with moderate activity, even in 15 individuals with cirrhosis (47%). During follow up, six subjects deteriorated clinically, appearing liver failure and three of these died 4, 5 and 14 years after the disease appearance. No subject developed a hepatocarcinoma.

Immunocytochemical staining of c-erb B-2 oncogene in fine-needle aspirates of breast carcinoma: a comparison with tissue sections and other breast cancer prognostic factors

The role of fine-needle aspiration (FNA) in breast cancer management is expanding to include prognostic in addition to diagnostic studies. This study was undertaken to compare the immunohistochemical staining of c-erbB-2, a breast cancer prognostic factor, on cytologic FNA smears of breast cancer with that on corresponding formalin-fixed, paraffin-embedded tissue sections of the same tumor and to correlate the c-erbB-2 expression with other known breast cancer prognostic factors. FNA smears (destained, alcohol-fixed, Pap-stained direct smears) and corresponding tissue sections (formalin-fixed, paraffin-embedded, unstained sections) from 36 primary breast carcinomas were stained immunohistochemically with c-erbB-2 antibody using an avidin-biotin procedure. Ten tumors (28%) showed strong positive staining for c-erbB-2 on the FNA smear and, of those ten, seven were positive on the corresponding tissue section and three were negative. In several of the cytology and tissue positive cases, staining on the tissue section was significantly weaker than on the FNA smear. Two cases involved treatment with preoperative chemotherapy; in one of those cases, tissue staining was weaker than cytologic staining, and, in the other case, both were negative. Correlation of c-erbB-2 staining with other prognostic factors showed an association between positive c-erbB-2 staining and high nuclear grade. Our results indicate that immunohistochemical staining for c-erbB-2 can be performed on destained FNA smears of breast carcinomas and may be more sensitive on the cytologic specimens than on formalin-fixed, paraffin-embedded tissue sections.

High incidence of monosomy 18 in lymphoid malignancies that have bone marrow and peripheral blood involvement

We studied the incidence of numerical chromosome 18 abnormalities in 107 patients with lymphoid malignancies by fluorescence in situ hybridization (FISH) using a directly conjugated centromeric probe for chromosome 18. Samples were obtained by fine needle aspiration of diseased nodes, bone marrows or peripheral blood. Monosomy 18 was more common in chronic lymphocytic leukemia (43%), small lymphocytic lymphoma (28%), and follicular lymphomas (12.5%) than in diffuse lymphomas (5.3%; p < 0.01). Monosomy 18 was detected in 9.7-17.1% of the cells in non-Hodgkin's lymphoma (NHL) (background, 5.4%; 99% CI, 4.2%-6.6%) and in 8%-16.7% (median, 10%) of the cells in (CLL) (background, 3.4%; 99% CI, 2.5%-4.3%). All patients with monosomy 18 were found to have bone marrow involvement. Of all untreated patients who had disease involving the bone marrow, 32% were found to have monosomy 18. Trisomy 18 was detected in 3.6%-48.2% of the cells in NHL (background, 0.9%; 99% CI, 0.2%-1.6%) and was most common in diffuse large-cell lymphoma (34%) and follicular lymphomas (31%). None of the patients with small lymphocytic lymphoma or chronic lymphocytic leukemia had trisomy 18. There was no correlation between trisomy 18 and response to treatment or clinical presentation. In this study, monosomy 18 was observed frequently in patients with lymphoid malignancies that involve the bone marrow and peripheral blood. Our data suggest that important gene(s) located on chromosome 18 may be involved in homing of the malignant lymphocytes to the bone marrow and peripheral blood.

Prognostic significance of signal-averaged electrocardiogram after thrombolytic therapy and/or angioplasty during acute myocardial infarction (CAST substudy). Cardiac Arrhythmia Suppression Trial (CAST) SAECG Substudy Investigators

Thrombolytic therapy and angioplasty during the early phase of an acute myocardial infarction (AMI) have been shown to improve prognosis. Time-domain analysis of the signal-averaged electrocardiogram (SAECG) provides strong, independent prediction of arrhythmic events (arrhythmic death/resuscitated cardiac arrest) after AMI. To determine whether the prognostic significance of an abnormal SAECG (QRS duration > or = 120 ms) measured after AMI is influenced by thrombolytic therapy/angioplasty given in the AMI period, the predictive value of SAECG was compared in patients with and without prior thrombolysis/angioplasty in a substudy of the Cardiac Arrhythmia Suppression Trial. Information was available in 787 patients. The average follow-up was 10 +/- 3 months and arrhythmic events occurred in 33 patients (4.2%). The prevalence of abnormal SAECG in patients with and without thrombolytic therapy/angioplasty was 9.4% (34 of 363 patients) and 14.9% (63 of 424 patients), respectively (p < 0.02). The arrhythmic event rate for patients with abnormal SAECG with and without thrombolytic therapy/angioplasty was 20.6% (7 of 34 patients) and 20.6% (13 of 63 patients), respectively. The arrhythmic event rate for patients with normal SAECG with and without thrombolytic therapy/angioplasty was 0.9% (3 of 329 patients) and 2.8% (10 of 361 patients), respectively. It is concluded that in patients with an AMI (1) the use of thrombolytic therapy/angioplasty is associated with a significantly decreased prevalence of abnormal SAECG, (2) thrombolytic therapy/angioplasty associated with a normal SAECG portends an excellent prognosis, and (3) an abnormal SAECG is predictive of an increased incidence of arrhythmic events in all patients regardless of prior thrombolytic therapy/angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Antianginal and anti-ischemic efficacy of immediate-release nisoldipine in chronic stable angina pectoris

A double-blind, randomized, placebo-controlled, crossover study tested peak and trough efficacy of immediate-release nisoldipine (20 mg twice daily) added to existent beta-adrenergic blocking therapy. Patients were randomized with a history of chronic stable angina, while receiving a stable regimen of a beta-blocking agent, with exercise test-induced angina in association with 1 mm horizontal or downsloping ST-segment depression and exercise test reproducibility of +/- 15%. Ambulatory electrocardiographic monitoring (48-hour) was performed at 3 of 5 centers (44 patients). Efficacy was achieved in 53 patients (26 taking immediate-release nisoldipine/placebo in sequence and 27 taking placebo/immediate-release nisoldipine in sequence). Total exercise time increased compared with placebo at peak, but only a trend was seen at trough. Time to 1 mm ST-segment depression at peak and trough and ambulatory electrocardiographic parameters were also improved. Adverse effects were mild. This trial confirms that immediate-release nisoldipine when added to existent beta-blocker therapy is an active antianginal and anti-ischemic agent, but that the immediate-release formulation loses its antianginal effect at the end of its dosing interval (9 to 14 hours). This drug is therefore being examined in a new extended-release formulation (Coat-Core).

Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion

OBJECTIVE

To determine the occurrence of narcotic withdrawal in critically ill children who receive continuous infusions of fentanyl.

DESIGN

Prospective case series.

SETTING

A university hospital pediatric intensive care unit.

PATIENTS

Twenty-three children, aged 1 wk to 22 months (mean 6 months), who required assisted mechanical ventilation and who received continuous infusions of fentanyl for > 24 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total fentanyl dose received, length of infusion, and peak infusion rate were recorded. Patients were evaluated for narcotic withdrawal by the Neonatal Abstinence Scoring System of Finnegan. Children with scores of > or = 8 were considered to have narcotic withdrawal. Withdrawal was observed in 13 (57%) of 23 infants. Total fentanyl dose (2.96 +/- 4.10 vs. 0.53 +/- 0.37 mg/kg, p < .005) and length of fentanyl infusion (13.1 +/- 11.3 vs. 3.8 +/- 1.5 days, p < .0001) were significantly greater in those infants with narcotic withdrawal than in those infants with no withdrawal, respectively. Peak fentanyl infusion rate (9.9 +/- 7.8 vs. 9.2 +/- 4.4 micrograms/kg/hr) did not differ significantly between the two groups. A total fentanyl dose of > 2.5 mg/kg or a duration of infusion of > 9 days was 100% predictive of withdrawal.

CONCLUSIONS

Continuous infusions of fentanyl produce a high occurrence rate of narcotic withdrawal when administered to critically ill children. This effect is both dose- and duration-dependent.

Polysomy of chromosome 12 in 60 patients with non-Hodgkin's lymphoma assessed by fluorescence in situ hybridization: differences between follicular and diffuse large cell lymphoma

Sixty consecutive evaluable specimens from patients with non-Hodgkin's lymphoma (NHL) were studied for the incidence of polysomy of chromosome 12 by fluorescence in situ hybridization (FISH) with probes for the repetitive DNA sequence in the centromeric region of chromosome 12. Thirty-six samples were from follicular lymphomas (FLs), and twenty-four were from diffuse large cell lymphomas (DLCLs). Fifty-two specimens (86%) were obtained by fine-needle aspiration of a diseased node, seven (11.6%) were from involved bone marrows, and one specimen was from a pleural effusion. Twelve of the thirty-six (33%) cases with FL had trisomy 12 in 3-41% of the cells (median, 10%) (normal controls had three signals in 1.4 +/- 0.7% of cells). Trisomy 12 was found in 62% of the patients who had had FL for more than 5 years. Nine of the twenty-four cases (37%) with DLCL had more than two copies of chromosome 12 in 4-92% of the cells (median, 78%), and all nine cases were of B-cell phenotype. Unlike FL cells, some DLCL cells had 4-6 copies of chromosome 12. In previously untreated patients, 54% of DLCLs and 26% of FLs had subpopulations of cells containing more than two copies of chromosome 12 (P = 0.04). Only 2/7 cases of DLCL with polysomy 12 had rearrangement of the BCL2 gene, indicating that the majority of DLCL cases with polysomy 12 did not result from histologic transformation of low grade follicular lymphomas. These data demonstrate that FISH of interphase cells is a sensitive method for detecting numerical abnormalities of chromosome 12 in NHL.(ABSTRACT TRUNCATED AT 250 WORDS)

Dose

The universal use of dose as a normalizing parameter in radiobiology is based entirely on the availability of measuring instruments. It is a poor basis for predicting or understanding the relationship between an irradiation and the resulting end point. Energy deposited is not the cause of an interaction. It is a secondary effect. The interaction is best described by fluence and cross section. Energy deposited depends principally upon inelastic collision cross sections for the interaction of electrons with molecules. Especially for heavy-ion bombardments, for high-LET radiations, inelastic electron collision cross sections relate only remotely to the observed end points of interest. When dose is used to describe effects observed with radiations of different "quality," response predictions can be very wide of the mark. One way to describe such a relationship is through the relative biological effectiveness (RBE). If we consider the RBE to be a correction factor to be applied to a prediction of response based on dose, we find that its values range from 0.01 to infinity. It is apparent that in general dose is a useless predictor of response, except in narrowly defined circumstances.