Managing healthcare costs, Part 1: The dilemma of AIDS

The costs of AIDS care can be reduced through individual case management, but first employers, insurers, and society in general must learn to deal with the disease and its victims rationally and compassionately.

Aerosol-perfusion lung scintigraphy: value of ventilation subtraction

99Tcm-labelled aerosol ventilation and 99Tcm-macroaggregate albumin (99Tcm-MAA) perfusion can be performed in the diagnosis of pulmonary embolism (PE). If both examinations are performed on the same day, the superposition of activity from the first scintigraphic examination might mask defects in the second. In this study, 106 examinations were carried out for suspected PE. Aerosol ventilation was performed first with 20 to 30 mCi 99Tcm-labelled rhenium sulphur (four views, 200,000 counts). Immediately afterwards, with the patient remaining in the same position, 5 to 7 mCi of 99Tcm-MAA were injected (four views, 400,000 counts). After normalization, aerosol activity was subtracted from perfusion images and unprocessed perfusion (UP) and ventilation subtraction perfusion (SP) images were compared. Interobserver diagnostic reproducibility between three readers was calculated both for UP and SP images. Intraobserver reproducibility between UP and SP images was calculated for each reader. Interobserver reproducibility was comparable for SP and UP images. Intraobserver reproducibility was good. Thus, whether ventilation was subtracted or not from perfusion images, there was no appreciable effect on perfusion defect detection. However, some perfusion abnormalities showed up more clearly on SP images. Perfusion can be performed immediately after aerosol ventilation; the images thus obtained are reliable for interpretation, and subtraction of ventilation is not necessary.

Atypical germ cells in prepubertal cryptorchid testes

Four cases of prepubertal cryptorchid testes with atypical germ cells were studied. These cells were characteristically large, showing a wide, pale cytoplasm and a large nucleus with both fine and coarse granular chromatin. Ferritin was shown to be absent. It is possible that these cells are dysplastic in nature and that they could form the basis of a premalignant intratubular lesion. Thus periodic follow-up of these patients is recommended.

Subacute spongiform encephalopathy with periodic paroxysmal activities: clinical evolution and serial EEG findings in 20 cases

Evolution of both clinical and EEG abnormalities was analyzed in 20 (16 pathologically confirmed) patients suffering from subacute spongiform encephalopathy with periodic paroxysmal activities (PPA) on the EEG. Illness duration was less than 4 and greater than 17 months in 65% and 10% of cases, respectively. All data but EEG were utilized to assess 3 conventional clinical stages in 20 patients. The early clinical stage was characterized by gradual presentation of gait disturbances, mental deterioration, sensory or autonomic disorders. In contrast with other reports, no PPA were observed in 10 EEG recordings from 7 patients examined at the early clinical stage. Both clinical and EEG findings were not in contrast with a hypothetic subcortical onset of disease. Similar to recent data in the literature, early PPA appeared within 12 weeks of disease evolution in 88% of patients who underwent EEG recordings in the first 3 months of disease. Nonetheless, these early PPA always occurred at an intermediary stage, when our patients showed a marked worsening of the clinical picture. Focal, segmental and/or generalized myoclonic jerks were observed in 15%, 53% and 100% of cases at prodromal, intermediary and terminal stages respectively. Different kinds of PPA were observed: bi-tri-phasic periodic complexes (PC), periodic complexes with multiphasic configuration (PPC) and periodic polyspiking discharges (PPD). Abnormal "pacing" of PC by slowly repeated flashes was found in 4 patients presenting visual hallucinations or cortical blindness. Burst-suppression activity was frequently found at the terminal stage in decorticate patients.

Bone disease induced by anticonvulsant therapy and treatment with calcitriol (1,25-dihydroxyvitamin D3)

To evaluate the effects of calcitriol (1,25-dihydroxyvitamin D3) therapy for the bone disease induced by long-term treatment with anticonvulsants, we reviewed the medical records of 330 institutionalized oligophrenic children and young adults under 26 years of age to identify the 144 children who required anticonvulsant therapy. Of this latter group, 52 children were found to have serum alkaline phosphatase levels elevated more than 2 SDs above normal and were enrolled into this prospective three-year study. To achieve rapid resolution of the bone disease, we elected to use calcitriol at 0.25 to 0.75 micrograms/d. After 1195 patient-months of treatment, our data suggest that the dystrophic process was reversed in 42.3% of the cases, as judged by decreases in serum alkaline phosphatase levels at six months, 65.4% of cases at 12 months, and 83.3% of cases at 13 to 18 months. By 30 months of follow-up, all patients showed significant lowering of serum alkaline phosphatase levels. The improvements were slow and gradual. Twenty-six patients in the treatment series of 52 patients initially showed signs of rickets or osteomalacia on roentgenograms of the wrists. Of these 26 patients, 12 (46%) showed improvement on roentgenograms within 24 months of the beginning of treatment. With reference to complications, hypercalcemia (calcium level, greater than 11 mg/dL [2.74 mmol/L]) was encountered at the rate of one episode per 44 patient-months of treatment. Our results strongly suggest that calcitriol is effective in healing anticonvulsant-related osteomalacia among children and youths, with a low incidence of complications.

Heterogeneity of the expression of class I and II HLA antigens in human breast carcinoma

HLA class I and II antigen expression was studied in 19 cases of primary infiltrating ductal carcinoma of the breast. An indirect immunofluorescence technique was used on cryostat sections with monoclonal antibodies directed against HLA class I and II monomorphic determinants. Of the 19 cases studied, 17 were positive for class I antigen expression and two were negative. Class I HLA antigen expression was found to be clearly heterogeneous: in ten of these tumours more than 75% of the cells were class I positive; in two the percentage was decreased to between 50% and 75%; in five tumours it was less than 50%. With respect to class II HLA antigen expression, eight breast tumours were totally negative while two were strongly positive (50-75%) and the nine remaining cases were less than 25% positive. In addition, radioassay techniques were employed to determine the presence of oestrogen and progestagen receptors. The distribution of these receptors was not correlated with HLA class I or II antigen expression, nor could any relationship be demonstrated between the degree of histological differentiation of the tumours and their invasiveness.

Medial collateral ligament healing. A multidisciplinary assessment in rabbits

Medial collateral ligament healing without treatment has been studied in a rabbit model. Complete midsubstance gaps were found to heal by distinct scar formation over time. This healing process was fast since the gap was bridged quickly; however, more subtle changes in appearance of the healing tissue continued for many months. The ligament "scar" was found to be structurally abnormal chemically and mechanically even at long-term followup. A plateau in its improvement suggests that the scar may never approach normal ligament characteristics (without treatment). A baseline of ligament healing by scar formation has been established.

Effect of starvation on the N-acetylglutamate system of rat liver

Rats fasted for 3 and 6 days showed an increase in the activity, per g of liver but not per total liver, of the mitochondrial urea cycle enzymes, carbamylphosphate synthetase and ornithine transcarbamylase. The activity of N-acetylglutamate synthetase, both per g and per total liver, increased by the third day and then decreased on the sixth day of fasting. The cytosolic enzyme N-acetyldeacylase showed the same general pattern as the N-acetylglutamate synthetase except that the relative proportion of synthetase over deacylase was higher at the third day of starvation. The N-acetylglutamate level/g liver increases in relation to the number of days of fasting.

Pressures in the sphincter of Oddi in patients with gallstones, common duct stones, and recurrent pancreatitis

To determine the significance of manometric pressure, measurements of the sphincter of Oddi in a control group and in patients with cholelithiasis with common duct stones with and without recurrent pancreatitis were studied. Sphincter of Oddi pressure was recorded continuously and by station pull-through by a triple lumen catheter. The basal sphincter of Oddi pressure, the mean pressure gradient between common duct and duodenum, and the sphincter of Oddi wave amplitude were measured. There was no significant difference between control subjects and patients with gallstones and common duct stones. In patients with common duct stones and recurrent pancreatitis the basal sphincter of Oddi pressure, the pressure gradient between common duct and duodenum, and the wave amplitude were significantly increased over control patients. These studies suggest that abnormalities in the sphincter of Oddi motor function are more common in patients with common duct stones with recurrent pancreatitis than in similar patients without pancreatitis.

Hepatic acetylator phenotype in diabetes mellitus

Hepatic acetylator phenotype was determined using the sulphamethazine method in 32 patients with juvenile-onset diabetes mellitus and in 87 patients with the maturity-onset diabetes mellitus (Types I and II) and among 157 controls. No statistical differences were observed, neither for the incidence of acetylator phenotype among diabetics as compared with the control group, nor for the age at diagnosis of maturity-onset diabetes in slow and rapid acetylators. The incidence of diabetic retinopathy was similar among both phenotypes.

Computer analyzed EEG in amphetamine-responsive hyperactive children

Electroencephalographic (EEG) frequency analysis and evoked potentials (EPs) of 27 hyperactive children were examined to determine which, if any, of these electrophysiological parameters might be useful for the selection of those children likely to respond to stimulant medication. The children were treated with placebo, d-amphetamine, and l-amphetamine in double-blind fashion and in random order. EEGs for frequency analysis, visual EPs, and auditory EPs were obtained before and during treatment. Off medication, hyperactive responders to amphetamine had higher predominant beta frequency and shorter latencies of some EP waves than did nonresponders. Although the findings reported here would not select all responders, they would allow the exclusion of most nonresponders.

Treatment of multiple viral warts with levamisole

Seventy-seven patients with multiple common warts were screened for a double-blind study using levamisole. Of these, only 32 patients showed cellular immune deficiency. Fourteen patients received 2.5 mg/kg, two days a week, for eight weeks, and eighteen received a placebo. Both groups showed some improvement but results were not statistically different. Placebo plays a significant role in the treatment of warts.