Results of gastric neutralization with hourly antacids and cimetidine in 320 intubated patients with respiratory failure

In a retrospective analysis massive upper gastrointestinal (GI) hemorrhage, defined as blood loss requiring more than two units of blood transfusion over a 24-hour period, occurred in 40 (9.5 percent) of 420 intubated, mechanically ventilated patients with respiratory failure, irrespective of the etiology of the respiratory failure. In a prospective study hourly antacid gastric neutralization, maintaining the gastric pH over 5, the incidence of massive gastric bleeding was reduced to 3 (1.4 percent) of 210 patients. In 110 additional patients, cimetidine, a histamine H2 receptor blocker, was used to prevent gastric acid secretion; 3 (2.7 percent) of 110 patients had massive upper GI bleeding; all three had solitary chronic pyloric ulcers. We conclude that gastric neutralization, either with hourly antacids or with cimetidine, is effective in reducing the incidence of massive gastric hemorrhage in intubated, mechanically ventilated patients during respiratory failure. We recommend the use of either in all intubated patients with respiratory failure. In addition, in 17 patients who had gastric bleeding at the time of transfer to the respiratory intensive care unit, gastric neutralization with hourly antacids in 14 patients and with cimetidine in three patients stopped the bleeding in all 17 patients within 24 to 48 hours.

Urinary catecholamines, plasma renin activity and blood pressure in newborns: effects of narcotic withdrawal

Blood pressure and plasma renin activity were studied in 13 infants of drug-dependent mothers (heroin and/or methadone) and 20 control newborns for a period of 21 days. Urinary excretion of epinephrine and norepinephrine were also measured at 24 and 48 h of age. The systolic blood pressure was found to be significantly elevated in newborns of drug-dependent mothers compared with controls (p less than 0.01), but diastolic blood pressure levels were similar. Plasma renin activity was significantly elevated (p less than 0.001) at 48-72 h and urinary epinephrine levels were significantly lower (p less than 0.05) at 24-48 h of age in the drug group, and norepinephrine levels were equivalent. Systolic hypertension and elevated plasma renin activity in these newborns of dependent mothers may be due to increased beta-adrenergic receptor sensitivity.

Trimipramine in the treatment of active duodenal ulceration

Forty-five patients with endoscopically proven uncomplicated active duodenal ulcers were placed in a randomised double-blind trial. Six patients were lost to follow-up. Twenty patients received 50 mg trimipramine (Surmontil) at night, and 19 patients received placebo. Complete healing was defined as disappearance of the ulcer, with or without a scar; partial healing was defined as a reduction of ulcer size to 25% of its size, or a large deep ulcer that became flat, if erosions were present even if the ulcer had gone. After 4 weeks of trimipramine treatment 35% had completely healed and 50% had partly healed, compared with 21% completely and 21% partly healed with placebo (chi-square 7.9; p less than 0.025 in favour of trimipramine). There were no side effects. Trimipramine, 50 mg at night, is a safe and effective treatment for active duodenal ulceration.

Relationship of thyroid hormone levels to the severity of the narcotic withdrawal syndrome

Serum T3, T4 and thyroid stimulating hormone (TSH) were evaluated in 24 neonates of mothers taking methadone and compared with 16 normal controls using cord serum and serum taken on days 1, 2, 3, 4, 7, and 14. Patients were divided into treated (Rx; n = 14) and not treated (No Rx; n = 10) groups based on withdrawal scores and correlated to thyroid hormone levels. T4 levels were greater in the Rx group when compared to controls on days 2, 4 and 7 (p less than 0.01) and when compared to the No Rx group on days 3 and 7 (p less than 0.005). No Rx patients had higher T4 levels when compared to controls on day 4 (p less than 0.05). In general T3 levels paralleled T4 results. TSH levels were decreased in the Rx group compared to No Rx and controls on day 2 (p less than 0.01). Lipsitz scores correlated with T4 levels on days 3, 4, and 7 in methadone patients (p less than 0.05) but did not correlate with T3 or TSH. These findings suggest a correlation between the severity of withdrawal symptoms and T4 and T3 levels.

Clinical evaluation of bronchopulmonary lavage using the flexible fiberoptic bronchoscope

Thirty-three patients had segmental and lobar bronchopulmonary lavage using three types of flexible fiberoptic bronchoscopes. A maximum volume of 300 ml of normal saline solution at room temperature was used. Lavage was effective for removing large numbers of alveolar macrophages (mean, 17 million) and proteinaceous material (mean, 0.18 mg per milliliter) that helped enhance the antibacterial properties of the macrophages. Transient shunting (mean fall in partial pressure of arterial oxygen, 65 mm Hg) and alveolar filling that reverted to normal in 3 hours were noted. The procedure averaged 45 minutes and was as simple as bronchoscopy. The larger the internal diameter of the bronchoscope (> 2.6 mm) the better suited it was for lavage. Sequential segmental lavage seems to offer the advantages of simplicity and technical ease over isolated lobar lavage with a balloon-tipped bronchoscope. It also has the advantage of simplicity over whole-lung lavage.

Bicitropeptide and cimetidine in the treatment of duodenal ulcers. A double-blind, double-dummy endoscopically controlled trial

In a double-blind endoscopic study of 55 patients with uncomplicated duodenal ulcers, treatment with the mucosal-protective agent, bicitropeptide (BCP-Compound), was superior to that with cimetidine (Tagamet) after 6 weeks. After the administration of bicitropeptide, 77% of ulcers had completely healed and 25% had partially healed, and after treatment with cimetidine 38% had completely healed and 38% had partially healed (chi 2 = 6,316; P < 0,025). There was no difference between the results of treatment with either drug at 12 weeks. Patients were followed up 3 months after the ulcers healed, and 44% who had been on bicitropeptide and 72% on cimetidine had active ulcers (no significant difference). Blood and urine bismuth levels were estimated before therapy, after 6 weeks of therapy, and after 3 months without therapy. Results showed that in patients taking bicitropeptide, urine bismuth levels rose significantly between 0 and 6 weeks, but decreased to pretreatment levels after 3 months without therapy. Blood bismuth levels did not change.

Sucralfate in the treatment of duodenal ulcers: a double-blind endoscopically controlled trial

This trend was maintained at 12 weeks (on sulcralfate 77% complete healing and 7% partial healing, on placebo 44% complete healing and 15% partial healing; chi 2 score 4,9402; P < 0,05). No statistically significant difference was achieved at 6 or 12 weeks for small ulcers. At 6 weeks, 73% of large ulcers were completely healed and 18% were partially healed compared with 21% on placebo completely and 43% partially healed (Fisher's exact P value of 0,092 in favour of sucralfate). No differences were found at 12 weeks. No side-effects were noted. Measurement of kaolin partial thromboplastin time and single-stage prothrombin time as measurement of heparin-like activity showed no differences before and after therapy. It is concluded that sucralfate is a safe and effective therapy for duodenal ulceration.

Effects of methadone on thyroid function in mother, fetus, and newborn

The effects of maternal use of methadone during pregnancy on tests of thyroid function were studied in 14 women and their offspring. Twelve normal nonaddicted women and their infants served as a control group. Concentrations of thyrotropin (TSH), thyroxine (T4), and triiodothyronine (T3) were not significantly different in maternal and cord serum, and in infant serum at age 24 hours. There was no significant difference in infants' TSH concentrations at 2, 3, and 7 days of age. At 2 and 7 days, T3 levels were significantly higher in the methadone than in the control group (P = .01 and less than .01, respectively). At 3 days, differences were of borderline significance (P = .08). Increased T4 levels in the methadone group of infants were statistically significant at 2 days (P less than .01) and at 3 and 7 days (P = .05). The mechanisms responsible for the biochemical evidence of hyperthyroidism were not determined, but may have been related to altered autonomic function and/or increased metabolic activity which occurs during neonatal narcotic withdrawal.

Variable X chromosomal abnormalities in patients with stigmata of Turner syndrome

Four cases with suspected sex chromosomal abnormalities and clinical features and endocrine data typical of Turner syndrome are presented. Chromosome preparations made from skin fibroblasts and peripheral blood and multiple banding techniques employed to map the genes of their X chromosomes showed variable results. A review of the literature also revealed conflicting findings regarding the mapping of genes on the X chromosome. Despite different cytogenetic findings, the clinical features of the four cases presented were quite similar.

Renal failure in the respiratory intensive care unit

The development of renal failure during respiratory failure is of grave prognostic significance. In 686 patients with respiratory failure, 74 developed renal failure; these had a mortality of 80%. The leading predisposing factors are: 1) gastrointestinal bleeding with hypovolemic shock; 2) sepsis with shock; 3) drug induced nephrotoxicity; and 4) hypotension. With antacid gastric neutralization, judicious use of nephrotoxic antibiotics, the incidence of renal failure can be reduced. Once renal failure occurs, early dialysis may increase the chances of recovery in these critically ill patients.

Reversible defect of neutrophil chemotaxis and random migration in primary hyperparathyroidism

Chemotactic and random migrations of neutrophils derived from four patients with primary hyperparathyroidism were found to be defective. These abnormalities improved significantly in parallel with the decrease in serum calcium and parathormone and with the increase in serum phosphorus concentration after surgical removal of the adenoma. These observation suggest a possible role for parathormone phosphorus and calcium in the motility of neutrophils.

Reversible platypnea and orthodeoxia following recovery from adult respiratory distress syndrome

Platypnea nad orthodeoxia developed during an episode of adult respiratory distress syndrome in a previously healthy individual. An outstanding feature of the patient's illness was the development of numerous pneumatoceles secondary to necrotizing pneumonia. These abnormalities spontaneously improved with improvement of the underlying parenchymal lung disease.

[Electron microscopic study of the DNA products of reverse transcription]

DNA-products synthesized on pre-mRNA's from rat liver and rabbit erythroidal bone marrow cells, on rabbit globin mRNA and the RNA-templates themselves have been examined by electron microscopy. In spreading conditions providing extension of molecules the sizes of DNA-products corresponded to sizes of RNA templates. Globin mRNA, pre-mRNA as well as cDNA synthesized on these templates in the presence of actinomycine D were seen as single-stranded molecules by electron microscopy. The preparations of cDNA synthesized in the absence of actinomycine D on the pre-mRNA template were represented by double-stranded molecules along side with sigle-sranded. Up to 10% of double-stranded DNA-product appeared to be branched; all branches of such molecules had the thickness and rigidity of double-stranded structures. The possible ways of formation of branched structures are discussed.

Primary amenorrhea in a black female with duplication and inversion of the secondary constriction regions of chromosome 9

A 36-yr-old black female presented with primary amenorrhea. The chromosomal constitution based on QFQ (Q bands by fluorescence using quinacrine) RFA (R bands by fluorescence using acridine orange), GTG (G band by Giemsa using trypsin), and CBG (C band by Giemsa using barium hydroxide) techniques was 46, XX, duplicated (9; q12), inverted (9; p12q12.1) in lymphocytes and skin fibroblasts. Both sex chromosomes were normal. Buccal smear revealed 22% Barr bodies. Duplication and inversion of secondary constriction regions of chromosome 9 may possibly be associated with abnormal clinical features.

The surgical treatment of pulmonary aspergillomas

During a 4 year period 11 patients underwent 12 operations for pulmonary aspergillomas. The usual reason for operation was hemoptysis--massive or moderate. There was one death after operation and two complications. One patient since has an aspergilloma on the opposite side and has recurrent hemoptysis. There may be an increasing incidence of aspergillomas secondary to a larger number of open negative tuberculosis patients in the population. The mortality rate from operation is under 10 percent, and the complications in the saprophytic infestation are few. Surgery is the preferred treatment for the good-risk patient.

Enlarging intratracheal tube cuff diameter: a quantitative roentgenographic study of its value in the early prediction of serious tracheal damage

A prospective study to radiographically document impending tracheal damage in patients on continuous mechanical ventilation was done in 135 intubated adult patients over an eighteen month period. The previously unrecognized enlarging cuff/trachea ratio over 150% was seen in 18 patients. Five of 9 patients who died with C/T ratio over 150% were autopsied; all had severe tracheal damage at the cuff site. Four of 5 patients who were decannulated/extubated developed tracheal stenosis at the cuff site, necessitating tracheal resection in 3 patients. Thus a C/T ratio over 150% is a reliable clinical indicator of tracheal damage. Some thoughts as to prevention of this iatrogenic disease are presented.

Conjunctival biopsy in sarcoidosis: A simple, safe, and specific diagnostic procedure

A prospective study was undertaken to determine the prevalence and specificity of granulomatous conjunctivitis in sarcoidosis. One hundred conjunctival biopsies were performed on patients with histologically confirmed sarcoidosis (60), pulmonary tuberculosis (25), and several nonspecific inflammatory diseases of the lung and eye (15). A positive biopsy was present in 33% of the patients with sarcoidosis, but in none of the other disease processes. Great care was taken to exclude the possibility of these granulomas being secondary to foreign body reaction or infection with tuberculosis or fungi. No predictive relationship could be established between eye symptoms or slit lamp findings in the conjunctiva and uveal tract, and the finding of positive conjunctival biopsies. Thus, it is suggested that this procedure, due to its ease, safety, and specificity, be the first biopsy performed in patients with clinical or chest x-ray abnormalities suggesting sarcoidosis.

Y-chromosomal genes in a phenotypic male with a 46XX karyotype

A number of patients with a male phenotype and a female (46XX) karyotype have been described. Although there is little or no evidence for the presence of a Y chromosome in their cells, these individuals resemble patients with Klinefelter syndrome (47XXY). Using a new serological assay for the presence of H-Y antigen, a cell surface component associated with the Y chromosome, we have demonstrated the presence of Y-chromosomal genes in a 46-year-old man with an XX karyotype. In addition, using standard cytological technique, we have located a minor population of XXY cells as well as cells bearing and abnormal chromosome 17 among the blood leukocytes of this individual.

Acute cardiomyopathy with recurrent pulmonary edema and hypotension following heroin overdosage

An 18-year-old man developed acute pulmonary edema following heroin overdose. Two days after initial improvement, there was recurrence of hypotension and pulmonary edema with severe hypoxemia refractory to mechanical ventilatory support utilizing positive and end-expiratory pressure. Cardiac catheterization revealed elevated pulmonary capillary wedge pressure suggestive of left ventricular failure. The use of digitalis and diuretics resulted in prompt clinical improvement and ultimate recovery. Evidence is presented indicating that this patient represents an uncommon but important syndrome of acute cardiomyopathy with left ventricular failure which complicates the clinical course of certain cases of heroin overdose. Its physiologic diagnosis is of obvious importance in the choice of proper therapy, thereby increasing the patient's chances of recovery.

Emergence of overt diabetes in offspring of rats with induced latent diabetes

A single subdiabetogenic dose of alloxan administered to the weanling rat induces a persistent state of latent diabetes which progresses to fasting hyperglycemia by the seventh generation. Initial descendants of alloxan-treated animals have hyperinsulinism which progresses to insulinopenia in later generations. Later generation animals develop ketoacidosis when challenged with a dose of alloxan that has no effect on control animals. The significant sex difference in glucose tolerance rates disappears as the animals become more diabetic and decreased fertility and parity become apparent. One explanation for this data remains the hypothesis of paramutation, induced by alloxan, affecting regulator gene activity. Light microscopy of diabetic animals shows no pathology.