Good clinical outcome in a patient with a large CT scan hypodensity treated with intra-arterial urokinase after an embolic stroke

Hypodense regions demonstrated by CT within 6 hours of the onset of stroke may reflect irreversibly damaged tissue, and some have suggested that patients with such findings should be spared the risks of thrombolytic therapy since they are unable to benefit from it. We report here a patient with a low-density area demonstrated by CT less than 6 hours after onset of symptoms who improved dramatically after successful intra-arterial thrombolysis.

The use of the eating disorder examination with children: a pilot study

OBJECTIVE

This article describes the use of a slightly modified version of the Eating Disorders Examination (EDE) in children.

METHODS

Sixteen children aged between 7 and 14 years attending an eating disorders clinic over a 5-month period were recruited to the study. The two main modifications to the EDE were (A) the inclusion of a sort task to assess overvalued ideas about weight and shape and (B) the reformulation of certain items to assess intent rather than actual behavior. The existing EDE scoring system was used, resulting in item, subscale, and global scores.

RESULTS

Of the 16 children (10 F 6 M), 11 had a diagnosis of anorexia nervosa, and 5 of eating disorder not otherwise specified (EDNOS). There were interesting differences in responses on items assessing core overvalued ideas, with weight and/or shape concerns emerging as of great importance in terms of self-evaluation in the majority of children with anorexia nervosa.

DISCUSSION

Results suggest that this may be a useful assessment tool in children, with some children obtaining global and subscale scores consistent with adult norms for females with eating disorders. Problems of the administration of the EDE to this patient group are discussed and details of the modifications used are outlined.

Idiom understanding in Australian youth: a cross-cultural comparison

In this developmental study, idiom understanding was examined in Australian students from Grades 5 and 8 (n = 50 per group; mean ages = 10.7 and 13.8, respectively). Twenty-four idioms with familiarity ratings ranging from high to low (as judged by Australian adolescents) were each presented in a brief story context. The students read each story and selected the best interpretation of the idiom from a set of four answer choices. Results indicated that performance on the task improved as a function of increasing grade level and that idiom familiarity was significantly correlated to idiom understanding for both groups of students. These results, which were consistent with a previous study of American students of comparable educational levels (Nippold & Taylor, 1995), provide further support for the "language experience" hypothesis of figurative language development. In replicating the previous developmental study, evidence of external validity is provided.

Cerebral arterial aneurysm formation and rupture in 20,767 elderly patients: hypertension and other risk factors

Cerebral arterial aneurysms are common in the general population and their rupture is a catastrophic event. Considerable uncertainty remains concerning the conditions that predispose individuals to aneurysm formation or rupture. The role of systemic hypertension in aneurysm formation and rupture has been especially controversial. Demographic variables have rarely been addressed because of the small sample sizes in previous studies. The authors describe the demographics and prevalence of hypertension in 20,767 Medicare patients with an unruptured aneurysm and compared these to a random sample of the hospitalized Medicare population. The prevalence of hypertension in patients with unruptured aneurysms was 43.2% compared with 34.4% in the random sample. Patients who survived their initial hospitalization were separated into two groups: those with an unruptured cerebral aneurysm as the primary diagnosis and those with an unruptured cerebral aneurysm as a secondary diagnosis. Follow-up data for 18,119 patients were examined to determine the risk of subarachnoid hemorrhage (SAH) associated with age, gender, race, hypertension, insulin-dependent diabetes mellitus, and surgical treatment. For patients with an unruptured cerebral aneurysm as the primary diagnosis, hypertension was found to be a significant risk factor for future SAH (risk ratio: 1.46, 95% confidence interval (CI): 1.01-2.11), whereas surgical treatment (risk ratio: 0.29, 95% CI: 0.09-0.97) had a significant protective effect. Advancing age had a small but significant protective effect in both groups. Elderly patients identified with unruptured aneurysms are more likely to have coexisting hypertension than the general hospitalized population. In elderly patients hospitalized with an unruptured cerebral aneurysm as their primary diagnosis, hypertension is a risk factor for subsequent SAH, whereas surgical treatment is a protective factor against SAH.

Idiom understanding in youth: further examination of familiarity and transparency

School-age children and adolescents (n = 150) enrolled in Grades 5, 8, and 11 were administered a forced choice task of idiom understanding that controlled for idiom familiarity and transparency. Performance on the task steadily improved during the targeted age range and was affected by the factors of interest: Idioms that were higher in familiarity and transparency were easier for students to understand than those that were less familiar and more opaque. The results of this study provide further support for the language experience hypothesis of figurative language development and for the hypothesis that metalinguistic activity, which itself becomes more sophisticated during the school-age and adolescent years, facilitates later language development. The study also suggests certain methodological implications for future research that examines the development of idiom understanding in youth.

Changing incidence and etiology of iatrogenic ureteral injuries

In the last decade there have been major advances in endoscopic surgery including ureteroscopy and laparoscopy, both of which may cause ureteral injury. We sought to determine if increased use of these procedures affected the frequency and nature of major iatrogenic ureteral injuries managed at our medical center. From 1980 to 1984 we treated 8 patients with such injuries compared to 19 patients treated from 1985 to 1989. The most recent period corresponded to the institution of ureteroscopy and the use of more aggressive laparoscopic procedures. Of the patients 14 sustained injuries at our center while 13 were referred from other institutions. Between 1985 and 1989 the incidence of injuries per total hospital admissions at risk increased from 4 to 11 per 10,000 (p = 0.0067), the incidence of urological injuries increased from 4 to 23 per 10,000 (p = 0.0071) and the incidence of injuries occurring in gynecologic patients increased from 13 to 41 per 10,000 admissions (p = 0.0385). There was no difference in the incidence of injuries in the general surgical population. From 1980 to 1984 no laparoscopic or ureteroscopic injuries occurred. However, from 1985 to 1989, 25% of gynecologic injuries occurred during laparoscopy and 70% of urological injuries were sustained during ureteroscopic procedures. Depending on the extent of the injury, patients were initially treated with either endourological or open surgical procedures. Good results were obtained in the majority of cases. Contemporary therapeutic strategies for treating patients sustaining ureteral injuries are discussed.

Incidence of renal anomalies in children prenatally exposed to ethanol

OBJECTIVE

Based on a number of studies involving animals as well as human case reports indicating an association between prenatal ethanol exposure and renal malformations, it has been suggested that children with fetal alcohol syndrome (FAS) should be screened for renal anomalies. The purpose of this study was to evaluate a group of children prenatally exposed to alcohol to determine the incidence of renal anomalies and to evaluate the need for such a screening procedure.

METHODS

Renal ultrasounds were performed on a total of 84 patients (68 children, 13 adolescents, and three adults). In addition to screening for malformations, renal size was studied. Data were analyzed using both chronologic and height-age as determinants of kidney size.

PATIENTS

Of these 84 patients, 51 (61%) had FAS, and 33 (39%) had a history of prenatal ethanol exposure but did not have FAS.

RESULTS

Three (3.6%) patients (one with FAS, two with prenatal ethanol exposure who did not have FAS) had significant renal abnormalities. This incidence was not significantly different from that found in ultrasound screening of newborns. The kidneys of children with both FAS and prenatal ethanol exposure who did not have FAS were significantly smaller than normal for both chronologic and height-age. When children were compared across chronologic ages, those with FAS had significantly smaller kidneys than those who had no evidence of FAS. After adjusting for height, the difference between these two groups was no longer significant.

CONCLUSIONS

Based on these data, children prenatally exposed to ethanol do not need to be screened for renal anomalies.

Doppler hemodynamic profiles of 82 clinically and echocardiographically normal tricuspid valve prostheses

BACKGROUND

Normal Doppler hemodynamics for tricuspid prostheses have not been well characterized in a large group of patients. Therefore, we analyzed comprehensive Doppler echocardiographic examinations of 82 patients with tricuspid prostheses that were normal by clinical and two-dimensional echocardiographic examinations to establish the normal hemodynamics of various types and sizes of tricuspid prostheses.

METHODS AND RESULTS

The earliest complete postoperative echocardiographic study from each patient was chosen for analysis. Doppler examinations were analyzed on an off-line station from tapes or Doppler strip charts. Early velocity, atrial velocity, end-diastolic velocity, pressure half-time, and mean gradient were obtained by digitizing tricuspid velocity curves. The incidence of "physiological" tricuspid prosthetic regurgitation was noted. Ten Doppler cycles were measured for each patient, and maximal, minimal, and average measurements were recorded. The mean values +/- SD of early velocity, atrial velocity, end-diastolic velocity, mean gradient, and pressure half-time and incidence of mild prosthetic regurgitation were reported for each type of prosthesis, as were highest Doppler measurements for each valve type. Average pressure half-time was significantly lower for St Jude than for heterograft prostheses (P = .04). There were no significant differences between the valve types for mean gradient, early velocity, or incidence of prosthetic regurgitation. Increasing prosthesis size was associated with lower average pressure half-time for heterograft prostheses (P = .024). Average differences (respiratory- and cycle-length-dependent) between maximal and minimal values for 10 cardiac cycles were established for each prosthesis.

CONCLUSIONS

This study establishes normal ranges for Doppler hemodynamics of various tricuspid prostheses and emphasizes the importance of measuring multiple cycles for each tricuspid prosthesis, regardless of cardiac rhythm.

Myelitis following chickenpox: a case report

An 18-year-old woman presented with myelopathic symptoms and a T-8 sensory deficit during a primary varicella infection. There were significant MRI changes in both the cervical and thoracic regions. Following treatment with steroids and intravenous acyclovir, the patient improved clinically and the abnormalities on MRI improved.

A homoallelic Gly317-->Asp mutation in ALPL causes the perinatal (lethal) form of hypophosphatasia in Canadian mennonites

We have discovered a single homoallelic nucleotide substitution as the putative cause of the perinatal (lethal) form of hypophosphatasia in Canadian Mennonites. Previous linkage and haplotype analysis in this population suggested that a single mutational event was responsible for this autosomal recessive form of hypophosphatasia. The mutation is a guanosine-to-adenosine substitution at nucleotide position 1177 in exon 10 of the tissue nonspecific (liver/bone/kidney) alkaline phosphatase gene. This Gly317-->Asp mutation segregates exclusively with the heterozygote phenotype we previously assigned by biochemical testing (maximum combined lod score of 18.24 at theta = 0.00). This putative disease-causing mutation has not been described in controls nor in other non-Mennonite probands with both lethal and nonlethal forms of hypophosphatasia studied to date. This Gly317-->Asp mutation changes a polar glycine to an acidic aspartate at amino acid position 317 within the highly conserved active site region of the 507-amino-acid polypeptide. Carrier screening for this lethal mutation in our high-risk population is now feasible.

Ocular tilt reaction resulting from vestibuloacoustic nerve surgery

The ocular tilt reaction (OTR) is a triad of head-eye synkinesis composed of head tilt, conjugate ocular torsion in the direction of head tilt, and skew deviation. The OTR represents a normal compensatory response to lateral head tilts and is produced by activation of the utricle of the lowermost ear. A pathological OTR results when otolith activity is unopposed as the result of injury to the opposite utricle or its nerve. Vertical diplopia may be the only symptom of OTR in patients who have undergone surgery involving the vestibuloacoustic nerve. We report a series of patients with OTR after surgery for acoustic neuroma or Meniere's disease. In each patient, the manifesting symptom was vertical diplopia. Bedside neuro-ophthalmological testing readily excluded a brain stem cause for the double vision. We conclude that OTR after vestibuloacoustic surgery is a benign condition with spontaneous resolution of symptoms within several months.

Regional cerebrovascular responses to progressive hypotension after traumatic brain injury in cats

We investigated the effects of hypotension on cerebral blood flow (CBF) after traumatic brain injury (TBI) in cats. Isoflurane-anesthetized cats were prepared for TBI and for microsphere measurements of total (T) and regional (r) CBF. Four groups were studied: sham injury (group I, n = 6); TBI (group II, n = 6); isoflurane anesthesia, no TBI or hypotension (group III, n = 4); and isoflurane and TBI, no hypotension (group IV, n = 8). After TBI or sham trauma, mean arterial pressure (MAP) was reduced to 80, 60, and 40 mmHg by hemorrhage. Group I TCBF did not change significantly from baseline until MAP reached 40 mmHg, but rCBF was more dependent on MAP in anterior hemispheric than in brain stem regions. Group II TCBF was significantly lower than baseline, and group I TCBF at all levels of hypotension and autoregulation was impaired at higher MAP levels in anterior than in posterior brain regions. Groups III and IV indicated that decreases in TCBF were not due to duration of the preparation or to TBI in the absence of hemorrhagic hypotension. We conclude that global and regional autoregulation are absent in response to hemorrhagic hypotension after TBI.

Measurement of globe position in complex orbital fractures. I. A modification of Hertel's exophthalmometer, using the external auditory canal as a reference point

Where there has been displacement or removal of the lateral orbital rim or zygomaticomaxillary complex secondary to trauma or surgery, the measure of globe position by the Hertel exophthalmometer is problematic and inaccurate. A modification of Hertel's instrument that uses the external auditory canal (EAC) rather than the orbital rim as reference point has been developed. Measurement of globe position of 120 normal volunteers was obtained with the Hertel and the modified EAC-fixated exophthalmometer. Although the mean absolute difference between right and left measurements for both methods (Hertel mean, 0.36 mm; modified mean, 0.51 mm; n = 120) differed statistically from 0 (p = 0.0001), that difference was not clinically significant. A more meaningful comparison was that of the variability of the two methods. The variance of the Hertel method (0.32) did not differ from the variance of the modified method (0.40; p = 0.06). No statistically significant difference was noted for sex (p = 0.33) or for race (p = 0.11). We believe this instrument to be of practical use in the assessment of enophthalmos or exophthalmos in patients whose facial deformity, trauma, surgery, or disease precludes the use of a rim-based exophthalmometry.

Reduced cerebral blood flow, oxygen delivery, and electroencephalographic activity after traumatic brain injury and mild hemorrhage in cats

The authors investigated the effects of transient, mild hemorrhagic hypotension after fluid-percussion traumatic brain injury on intracranial pressure, cerebral blood flow (CBF), cerebral oxygen delivery (CBF x arterial O2 content), and electroencephalographic (EEG) activity. Adult mongrel cats were anesthetized with 1.6% isoflurane in N2O:O2 (70:30) and prepared for trauma and for radioactive microsphere CBF measurement. Isoflurane concentration was decreased to 0.8%, and the cats were randomly assigned to one of four control groups or to an experimental group. Animals in the four control groups underwent either mild hemorrhage (18 ml.kg-1) immediately followed by resuscitation with equal volumes of 10% Hetastarch (eight cats), mild hemorrhage followed by replacement of shed blood (six cats), isovolemic hemodilution with 18 ml.kg-1 of Hetastarch (six cats), or moderate (2.2 atm) trauma alone (eight cats). The experimental group received a combination of trauma and mild hemorrhage followed by resuscitation with Hetastarch (eight cats). Mild hemorrhage produced no significant changes in CBF, renal blood flow, or cardiac output. Following resuscitation from mild hemorrhage, mean arterial blood pressure, cardiac output, renal blood flow, and CBF were not significantly different from baseline; cardiac output and renal blood flow did not differ significantly from baseline 2 hours after Hetastarch resuscitation. Neither hemorrhage nor trauma alone produced significant decreases in CBF or in EEG activity, but trauma followed by hemorrhage and resuscitation produced significant (p less than 0.01) decreases in CBF, cerebral oxygen delivery, and EEG score. These data demonstrate that, following traumatic brain injury, even mild hemorrhagic hypotension is associated with significant deficits in cerebral oxygen availability and neurological function.

HIV prevention: a dramaturgical analysis and practical guide to creating safer sex interventions

Safer sex is currently a major strategy for preventing HIV transmission. We examine safer sex interventions using an interactionist form of dramaturgical analysis. This approach yields a dynamic model with which to generate novel safer sex interventions highly sensitive to changing individual, cultural, and social variables. Our goal is to help medical anthropologists, applied social scientists, health educators, community outreach specialists, and those who are sexually active apply safer sex strategies more effectively.

Cerebrovascular and cerebral metabolic effects of alterations in perfusion flow rate during hypothermic cardiopulmonary bypass in man

Recent experimental and clinical investigations provide conflicting evidence regarding the effects of changes in the systemic flow rate from the pump oxygenator on cerebral blood flow and the cerebral metabolic rate of oxygen consumption. However, the results of existing clinical studies are difficult to interpret because of the confounding effects of differences in management of arterial carbon dioxide tension and use of anesthetic and vasoactive agents during cardiopulmonary bypass. To clarify the relationship among perfusion flow rate, cerebral blood flow, and cerebral metabolic rate of oxygen consumption in man during hypothermic cardiopulmonary bypass, we varied perfusion flow rate in random order to either 1.75 or 2.25 L.min-1.m-2 and studied cerebral blood flow (measured by clearance of xenon 133) and cerebral metabolic rate of oxygen consumption (estimated as the product of cerebral blood flow and the cerebral arteriovenous oxygen content difference) in patients managed with both the alpha-stat (group 1) and the pH-stat (group 2) methods of pH and arterial carbon dioxide tension adjustment. We measured the cerebral arteriovenous oxygen content difference using radial arterial and jugular venous bulb blood samples. In each patient other variables known to exert effects on cerebral blood flow and cerebral metabolic rate of oxygen consumption, including temperature, arterial carbon dioxide tension, arterial oxygen tension, mean arterial pressure, and hematocrit, were maintained constant between measurements. In both groups, mean arterial pressure at both pump flow rates was similar because of spontaneous reciprocal alterations in systemic vascular resistance, that is, as perfusion flow rate declined, systemic vascular resistance increased; as perfusion flow rate increased, systemic vascular resistance declined. Under these tightly controlled conditions, pump flow variation per se exerted no effect on cerebral blood flow or cerebral metabolic rate of oxygen consumption in either group.

Hypertonic/hyperoncotic fluid resuscitation after hemorrhagic shock in dogs

We compared canine systemic and cerebral hemodynamics after resuscitation from hemorrhagic shock with 4 mL/kg (a volume approximating 12% of shed blood volume) of 7.2% saline (HS; 1233 mEq/L sodium), 20% hydroxyethyl starch (HES) in 0.8% saline, or a combination fluid consisting of 20% hydroxyethyl starch in 7.2% saline (HS/HES). Eighteen endotracheally intubated mongrel dogs (18-24 kg) were ventilated to maintain normocarbia with 0.5% halothane in nitrous oxide and oxygen (60:40). After a 30-min period of hemorrhagic shock (mean arterial blood pressure = 40 mm Hg), extending from time T0 to T30, animals received one of three randomly assigned intravenous resuscitation fluids: HS, HES, or HS/HES. Data were collected at baseline, at the beginning and end of the shock period (T0 and T30), immediately after fluid infusion (T35), and at 60-min intervals for 2 h (T95, T155). After resuscitation, mean arterial blood pressure and cardiac output increased similarly in all groups, but failed to return to baseline. Intracranial pressure decreased during shock and increased slightly, immediately after resuscitation in all groups. During shock, cerebral blood flow (cerebral venous outflow method) declined in all groups. After resuscitation, cerebral blood flow increased, exceeding baseline in the HS and HS/HES groups but remaining low in the HES group (P less than 0.05 HS vs HES at T35). We conclude that small-volume resuscitation (4 mL/kg) with HS, HS/HES, or HES does not effectively restore or sustain systemic hemodynamics in hemorrhaged dogs. In dogs without intracranial pathology, the effects on cerebral hemodynamics are also comparable, except for transiently greater cerebral blood flow in the HS group in comparison with the HES group.

Regional cerebral blood flow following resuscitation from hemorrhagic shock with hypertonic saline. Influence of a subdural mass

After severe hemorrhage, hypertonic saline restores systemic hemodynamics and decreases intracranial pressure (ICP), but its effects on regional cerebral blood flow (rCBF) when used for resuscitation of experimental animals with combined shock and intracranial hypertension have not been reported. We compared rCBF changes (by radiolabeled microsphere technique) after resuscitation from hemorrhage with either 0.8 or 7.2% saline in animals with and without a right hemispheric subdural mass. We studied 24 mongrel dogs anesthetized with 0.5% halothane and 60% nitrous oxide. In group 1 (n = 12), hemorrhage reduced mean arterial pressure (MAP) to 45 mmHg for 30 min. In group 2 (n = 12), ICP was increased and maintained constant at 15 mmHg, whereas hemorrhage reduced MAP to 55 mmHg for 30 min (cerebral perfusion pressure [CPP] approximately 40 mmHg in each group). After the 30-min shock period, 6 animals in each group received one of two randomly assigned resuscitation fluids over a 5-min interval: 1) 7.2% hypertonic saline (HS; sodium 1,232 mEq.l-1, volume 6.0 ml.kg-1); or 2) 0.8% isotonic saline (SAL; sodium 137 mEq.l-1, volume 54 ml.kg-1). Once fluid resuscitation began, ICP was permitted to vary independently in both groups. Data were collected at baseline (before subdural balloon inflation in group 2), midway through the shock interval (T15), immediately after fluid infusion (T35), and 60 and 90 min later (T95, T155). In groups 1 and 2, ICP was significantly less in animals resuscitated with HS compared to those receiving SAL (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Sodium nitroprusside infusion does not dilate cerebral resistance vessels during hypothermic cardiopulmonary bypass

This study determined whether sodium nitroprusside (SNP) changes cerebral vascular resistance during stable, hypothermic cardiopulmonary bypass (CPB). Cerebral blood flow (CBF) was measured using Xenon clearance in 39 patients anesthetized with fentanyl. In 25 patients (group 1), CBF was measured before and during infusion of SNP at a rate sufficient to reduce mean arterial pressure (MAP) approximately 20%. In 14 other patients (group 2), CBF was measured before and during simultaneous infusion of SNP and phenylephrine; SNP was continued at a rate that had reduced MAP approximately 20% while phenylephrine was added in a dose sufficient to restore MAP to preinfusion levels. Patients within each group were randomized to maintenance of PaCO2 approximately 40 mmHg (groups 1a and 2a), uncorrected for body temperature, or to maintenance of PaCO2 approximately 50 mmHg (groups 1b and 2b). The following variables were maintained within a narrow range: nasopharyngeal temperature (26-29 degrees C), pump oxygenator flow (1.7-2.5 l.min-1.m-2), PaO2 (150-300 mmHg), and Hct (22-28 vol%). In each patient, controlled variables varied no more than +/- 5% between measurements. In group 1a (PaCO2 approximately 40 mmHg), MAP was 86 +/- 9 mmHg (mean +/- SD) before and 65 +/- 8 mmHg during SNP infusion (P less than 0.0001). CBF was 12 +/- 3 ml.100g-1.min-1 before and 10 +/- 2 ml.100(-1).min-1 during SNP infusion (P less than 0.01). In group 1b (PaCO2 approximately 55 mmHg), MAP was 86 +/- 11 mmHg before and 66 +/- 13 mmHg during SNP infusion (P less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of anatrophic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghorn calculi

A retrospective study was conducted comparing anatrophic nephrolithotomy (10 cases), percutaneous nephrolithotomy alone (4 cases) or percutaneous nephrolithotomy combined with extracorporeal shock wave lithotripsy (23 cases) for the treatment of large staghorn calculi. A comparison based on collecting system anatomy demonstrated that anatrophic nephrolithotomy resulted in a greater stone-free rate, shorter hospitalization and lower costs while complication rates were similar. Anatrophic nephrolithotomy should still be considered a viable treatment option, especially for patients with large branched calculi in complex collecting systems.

Improved lung preservation with cold air storage

Conventional topical slush cooling limits lung transport to 4 to 6 hours. For this canine study of an alternate air cooling system, 37 canine lungs were removed: 24 were placed in plastic bags, and inserted in a Transplanthermm container at core air temperatures (n = 6 lungs each) of (A) 4 degrees C, (B) 8 degrees C, (C) 12 degrees C, and (D) 20 degrees C; 6 were stored conventionally in ice slush (E); and 7 were transplanted immediately (F). After 8 hours, the stored lungs were transplanted and the contralateral pulmonary artery was ligated. Survival, arterial oxygen tension, and extravascular lung water were monitored at 15 minutes and every hour for 4 hours. Four-hour survival was 100% in groups A, B, and F; 83% in group C, 50% in group D, and 17% in group E. The mean arterial oxygen tension at 1 hour was lower in group E (6.4 +/- 2.4 kPa) than in group A (39.8 +/- 13.2 kPa) (p = 0.0002) or in group F (42.0 +/- 16.2 kPa) (p = 0.0035). Extravascular lung water in group E was higher at 15 minutes (15.44 +/- 5.63 mL/kg) than in group A (3.76 +/- 0.63 mL/kg) (p = 0.0001) and group F (4.69 +/- 1.65 mL/kg) (p = 0.003). Cold air storage appears to provide better lung preservation than hypothermic immersion in ice slush.

Cerebrovascular Effects of Small Volume Resuscitation from Hemorrhagic Shock

To determine if hypertonic and hyperoncotic resuscitation solutions exerted comparable effects on cerebral hemodynamics following hemorrhagic shock, we compared randomly assigned, equal volumes (6.0 ml/kg) of hypertonic (7.2%) saline (HS) and hyperoncotic (20%) hydroxyethyl starch (HES) for resuscitation from acute experimental hemorrhage in 12 anesthetized dogs. Regional cerebral blood flow (radiolabeled microspheres), intracranial pressure (cisternal catheter), and systemic hemodynamics were recorded. Rapid hemorrhage reduced the mean arterial pressure to 45 mm Hg for 30 min. Resuscitation fluids were infused over 5 min. Both fluids restored mean arterial pressure and cardiac output equally. However, at 60 min following resuscitation, cardiac output decreased in the HS group in comparison to the HES group (1.7 +/- 0.1 vs. 3.1 +/- 0.2 L/min, p <0.05). Cardiac output rapidly declined, however, in the HS group in comparison to the HES group (p <0.05 60 min following resuscitation). Intracranial pressure and cerebral perfusion pressure were similar at all intervals. Regional cerebral blood flow was similar following both fluids. Neither fluid restored cerebral oxygen transport to baseline values. Based on these data, the authors conclude that, following severe hemorrhagic shock of brief duration, systemic and cerebral hemodynamic values are restored equally well by highly concentrated colloid or by hypertonic saline, although hypertonic saline only transiently improves cardiac output.

Small-volume resuscitation from hemorrhagic shock in dogs: effects on systemic hemodynamics and systemic blood flow

BACKGROUND AND METHODS

This study compared canine systemic hemodynamics and organ blood flow (radioactive microsphere technique) after resuscitation with 0.8% saline (Na+ 137 mEq/L), 7.2% hypertonic saline (Na+ 1233 mEq/L), 20% hydroxyethyl starch in 0.8% saline, or 20% hydroxyethyl starch in 7.2% saline, each in a volume approximating 15% of shed blood volume. Twenty-four endotracheally intubated mongrel dogs (18 to 24 kg) underwent a 30-min period of hemorrhagic shock, from time 0 to 30 min into the shock period, followed by fluid resuscitation. Data were collected at baseline, 15 min into the shock period, immediately after fluid infusion, 5 min after the beginning of resuscitation, and at 60-min intervals for 2 hr, (65 min after the beginning of resuscitation, and 125 min after the beginning of resuscitation). The animals received one of four randomly assigned iv resuscitation fluids: saline (54 mL/kg), hypertonic saline (6.0 mL/kg), hydroxyethel starch (6.0 mL/kg) or hypertonic saline/hydroxyethyl starch (6.0 mL/kg).

RESULTS

Mean arterial pressure increased in all groups after resuscitation. Cardiac output increased with resuscitation in all groups, exceeding baseline in the saline and hypertonic saline/hydroxyethyl starch groups (p less than .05 compared with hypertonic saline or hydroxyethyl starch). Sixty-five minutes after the beginning of resuscitation, cardiac output was significantly (p less than .05) greater in either of the two colloid-containing groups than in the hypertonic saline group. After resuscitation, hypertonic saline and hydroxyethyl starch produced minimal improvements in hepatic arterial flow, hypertonic saline/hydroxyethyl starch increased hepatic arterial flow to near baseline levels, and saline markedly increased hepatic arterial flow to levels exceeding baseline (p less than .05, saline vs. hydroxyethyl starch). One hundred twenty-five minutes after the beginning of resuscitation, hepatic arterial flow had decreased in all groups; hepatic arterial flow in the hypertonic saline group had decreased to levels comparable with those during shock. Myocardial, renal, and brain blood flow were not significantly different between groups.

CONCLUSIONS

Small-volume resuscitation with the combination of hypertonic saline/hydroxyethyl starch is comparable with much larger volumes of 0.8% saline, and is equal to hypertonic saline or hydroxyethyl starch in the ability to restore and sustain BP and improve organ blood flow after resuscitation from hemorrhagic shock.

Cerebral blood flow decreases with time whereas cerebral oxygen consumption remains stable during hypothermic cardiopulmonary bypass in humans

Recent investigations demonstrate that cerebral blood flow (CBF) progressively declines during hypothermic, nonpulsatile cardiopulmonary bypass (CPB). If CBF declines because of brain cooling, the cerebral metabolic rate for oxygen (CMRO2) should decline in parallel with the reduction in CBF. Therefore we studied the response of CBF, the cerebral arteriovenous oxygen content difference (A-VDcereO2) and CMRO2 as a function of the duration of CPB in humans. To do this, we compared the cerebrovascular response to changes in the PaCO2. Because sequential CBF measurements using xenon 133 (133Xe) clearance must be separated by 15-25 min, we hypothesized that a time-dependent decline in CBF would accentuate the CBF reduction caused by a decrease in PaCO2, but would blunt the CBF increase associated with a rise in PaCO2. We measured CBF in 25 patients and calculated the cerebral arteriovenous oxygen content difference using radial arterial and jugular venous bulb blood samples. Patients were randomly assigned to management within either a lower (32-48 mm Hg) or higher (50-71 mm Hg) range of PaCO2 uncorrected for temperature. Each patient underwent two randomly ordered sets of measurements, one at a lower PaCO2 and the other at a higher PaCO2 within the respective ranges. Cerebrovascular responsiveness to changes in PaCO2 was calculated as specific reactivity (SR), the change in CBF divided by the change in PaCO2, expressed in mL.100 g-1.min-1.mm Hg-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Binding of S protein by Neisseria gonorrhoeae and potential role in invasion

An agglutination assay was used to examine the binding of purified human S protein (vitronectin, serum spreading factor) to 201 clinical isolates of Neisseria gonorrhoeae. Strains belonging to the protein IA serovars were significantly (P less than 0.001) more reactive in agglutination tests with human S protein and were more serum resistant than strains belonging to the protein IB serovars. The strains from patients with disseminated infections belonged predominantly to the IA serovar (19 of 23) and, with the exception of IA-4 and certain IB serovars, avidly agglutinated with S protein. The serovar IA-4 and IB strains isolated from joint or cerebrospinal fluid failed to agglutinate with S protein and appeared to be less serum resistant than most other IA isolates. Cysteine hydrochloride or 2-mercaptoethanol inhibited agglutination of S protein and a more than twofold increase in resistance to killing by fresh human serum following preincubation with S protein; the serum-sensitive parent strain did not agglutinate S protein, and serum resistance was not increased following preincubation with this protein. Binding of S protein by gonococci may represent a novel pathogenic mechanism that can contribute to serum resistance.

Serial Doppler echocardiographic follow-up of left ventricular diastolic function in cardiac amyloidosis

A spectrum of left ventricular diastolic filling abnormalities noted on Doppler echocardiography has been demonstrated in patients with cardiac amyloidosis. To determine how these filling abnormalities evolve over time and the significance of any change, serial pulsed wave Doppler studies of left ventricular inflow were performed over 12.6 +/- 4.9 months in 41 consecutive patients (36 men and 15 women, mean age 59 +/- 11 years) with typical two-dimensional echocardiographic features of cardiac involvement. The measurements were peak left ventricular inflow in early diastole (E) and atrial contraction (A) velocities, E/A ratio, deceleration time and isovolumetric relaxation time. Patients were classified by mean left ventricular wall thickness into an early group (less than 15 mm) of 24 patients and an advanced group (greater than or equal to 15 mm) of 17 patients. The total group showed an increased E/A ratio (1.7 +/- 0.9 versus 1.4 +/- 0.9, p = 0.009) and decreased deceleration time (164 +/- 57 versus 174 +/- 51 ms, p = 0.11) at follow-up compared with baseline study. The early group showed significant changes in the E/A ratio (1.6 +/- 1.0 versus 1.2 +/- 0.7, p = 0.001) between the two studies. Seven patients (29%) in the early group showed a change from an abnormal relaxation or "normal" pattern to one of restriction, coincident with increased symptoms in six of these patients. Fifteen (88%) of the 17 patients in the advanced group did not show significant changes in the measures during the follow-up study, but these patients already showed a restrictive pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

Ileostomy using an interposed ileal segment to function as a 'neocolon'

A new type of ileostomy was constructed in rats using an interposed ileal (I-I) segment functioning as a neocolon. The effects of this operation in these rats were compared with a control group undergoing conventional ileostomy (I). Rats in the I group lost weight throughout follow-up, whereas rats in the I-I group regained weight and were significantly heavier four weeks after surgery. Transit time from the stomach to the stoma was significantly prolonged in the I-I group (187 +/- 29 minutes) when compared with the I group (141 +/- 17 minutes, P less than 0.01). Serum analysis revealed no significant differences in total protein, lipids, electrolytes (Na, Cl, CO2), and osmolarity between the groups. Biliary bile salt concentration, normalized bile flow, and normalized bile acid output in the I-I group were not different from those in unoperated control rats, suggesting unimpaired bile acid metabolism. These data suggest this operative procedure has the beneficial effects of slowing intestinal transit and promoting postoperative recovery without impairing distal ileal function.

Long term propranolol treatment and changes in body weight after myocardial infarction

OBJECTIVE

To determine the effect of long term propranolol treatment on body weight.

DESIGN

Retrospective analysis of data from a placebo controlled randomised double blind clinical trial (the beta blocker heart attack trial).

PATIENTS

3837 Men and women randomised 5-21 days after an acute myocardial infarction to treatment with placebo or propranolol for up to 40 months. Patients were followed up at annual visits.

MAIN OUTCOME MEASURE

Changes in body weight.

RESULTS

At the first annual visit patients treated with propranolol had gained more weight than those given placebo (mean weight gain 2.3 kg v 1.2 kg respectively, mean difference 1.2 kg (95% confidence interval 0.9 to 1.5]. These group differences remained at the second and third annual visits. The difference in weight gain could not be explained by discrepancies in the use of diuretics or in physical activity and was similar in patients of both sexes and of all ages.

CONCLUSION

Long term beta blockade results in a sustained weight gain.

Progression of aortic stenosis in adults: new appraisal using Doppler echocardiography

This study examined progression of aortic stenosis (AS) as assessed by Doppler echocardiography. One hundred twelve consecutive adult patients had calcific AS and underwent three examinations during a mean 25-month period (range 7 to 54 months). At the time of entry into the study, mean values for initial peak aortic velocity and ejection fraction (EF) were 2.9 +/- 0.7 m/sec and 63 +/- 10%, respectively; 52% of the patients were symptomatic. At the third examination the percentage of symptomatic patients increased to 65% (p = 0.0039 compared to baseline values), and the aortic peak velocity increased to 3.3 +/- 0.8 m/sec (p less than 0.001). Age, sex, and EF were not predictors of progression. Documented coronary artery disease (in 57 patients) did not affect progression, and neither did the aortic peak velocity at the time of entry into the study. Thirty-eight patients reported an increase in symptoms from the first to third examination, and their rate of progression was significantly different from that of the rest of the population: 0.33 +/- 0.50 m/sec/yr compared to 0.18 +/- 0.26 m/sec/yr (p less than 0.03).

Age-related prevalence of valvular regurgitation in normal subjects: a comprehensive color flow examination of 118 volunteers

We prospectively assessed the influence of aging on the prevalence of valvular regurgitation by using color flow imaging. One hundred eighteen healthy volunteers (21 to 82 years old) had a two-dimensional Doppler echocardiographic study that included color flow imaging to assess valvular regurgitation and that was semiquantitated by mapping the dimensions of the color flow regurgitant jet in orthogonal views. The subjects were divided into two groups: group 1 consisted of subjects who were younger than 50 years old (n = 61), and group 2 consisted of subjects who were at least 50 years old (n = 57). Mitral regurgitation was detected in 57 (48%) of the 118 subjects: 24 subjects (39%) in group 1 and 33 subjects (58%) in group 2. The severity of mitral regurgitation was trivial to mild. Aortic regurgitation was detected in 13 (11%) of the 118 subjects, all in group 2. The severity was trivial to mild. Tricuspid regurgitation was detected in 77 (65%) of the 118 subjects: 35 (57%) in group 1 and 42 (74%) in group 2. The severity was trivial to mild. Pulmonary regurgitation was detected in 24 (31%) of 78 subjects: nine (22%) in group 1 and 15 (41%) in group 2. The severity was trivial. These findings suggest that valvular regurgitation of a trivial or mild degree is a frequent finding in normal subjects and that it increases with age.

Factors associated with the recommendation for endocarditis prophylaxis in mitral value prolapse

We conducted a population-based study to examine the association between clinical and Doppler echocardiographic characteristics and physicians' recommendation for endocarditis prophylaxis. Of 127 consecutive Olmsted County, Minnesota, residents with newly documented isolated mitral valve prolapse, endocarditis prophylaxis was recommended three to four times more often in patients under 40 years compared with those more than 60 years of age. Using multiple logistic regression, for every 10-year increment in age, there was a 30% independent reduction in recommendations for endocarditis prophylaxis. Doppler evidence of mitral regurgitation was also independently associated with recommendations for endocarditis prophylaxis. Observations from physical examination, including systolic murmur and systolic click, were weakly associated with endocarditis prophylaxis recommendations. Mitral valve appearance (thickened vs not) was not associated with endocarditis prophylaxis. Although current recommendations for endocarditis prophylaxis and mitral valve prolapse do not address age and Doppler-detected mitral regurgitation, these variables are strongly associated with clinical decisions. Prospective, longitudinal, population-based studies are needed to define endocarditis risk further in subgroups with mitral valve prolapse to provide a more scientific basis for clinical decision making.

Level of agreement between questionnaire measures of alcohol dependence, alcoholism and problem drinking in a sample presenting at a specialist alcohol treatment service

Two questionnaire measures of the alcohol dependence syndrome, one of alcoholism, and one of alcohol-related problems were compared in a sample of 101 subjects attending a specialist alcohol treatment unit. There was substantial agreement between the two measures of alcohol dependence, and lesser agreement between any other pairing. The measures of alcohol dependence also showed the strongest correlation with reported weekly alcohol consumption. The findings are compared with previous research, and the suitability of the various questionnaires as case-defining instruments in empirical investigations is discussed.

Utility of color flow imaging for visualizing shunt flow in atrial septal defect

Color flow imaging provides visualization of intracardiac blood flow. The usefulness of this technique was evaluated in 93 patients with atrial septal defect. Color flow imaging improves the sensitivity of two-dimensional Doppler echocardiography in the diagnosis of atrial septal defect. In addition, it enhances communication between the cardiologist and the cardiovascular surgeon.

Aortic dissection: review of value and limitations of two-dimensional echocardiography in a six-year experience

The utility of transthoracic two-dimensional echocardiography in patients with aortic dissection was assessed by retrospective analysis in 67 patients: 31 patients with DeBakey type I, 21 patients with type II, 10 patients with type III, and five patients with false-positive diagnoses. Aortic dissection was correctly identified by two-dimensional echocardiography in 49 patients; 13 had false-negative diagnoses. Therefore the sensitivity was 79%, and the positive predictive accuracy was 91%. Transthoracic two-dimensional echocardiography is a reasonable screening technique for diagnosis of aortic dissection.

Prospective study of alcohol-related admissions in an inner-city hospital

Of 2598 acute admissions to the intensive therapy unit and medical, surgical, orthopaedic, and casualty wards of a general hospital in London, 313 (12%) were definitely alcohol related. Over half (163) the patients concerned were aged between 14 and 40 and 70% (219) were male. The proportion of alcohol-related admissions varied from 7.2% for a general surgical ward up to 26.3% for the casualty overnight observation ward. Substantially higher than average rates of alcohol-related admission were seen in Irish, Scottish, and Polish patients. Of the 23 deaths in the beds under scrutiny in patients aged 17-60 years, 9 were directly attributable to acute or chronic alcohol abuse.

Effects of ankle-foot orthoses on functional motor performance in a child with spastic diplegia

A pilot case study examining the effects of inhibitive ankle-foot orthoses on functional motor performance in a child with spastic diplegia is presented. Both qualitative and quantitative changes occurred, lending support to the efficacy of inhibitive orthoses in improving motor performance in children with cerebral palsy.

Modulation of cellular immune responses in mice with disseminated histoplasmosis by recombinant interleukin-2

Depression of the cellular immune responses in mice with disseminated histoplasmosis is associated with deficient production of interleukin-2 (IL-2) by splenocytes. Therefore, we examined whether a highly purified preparation of IL-2, recombinant human IL-2 (rIL-2), could modify the cellular immune responses in infected mice and whether this lymphokine could alter the severity of histoplasmosis in animals. Exogenous rIL-2, at concentrations of up to 1,000 U/ml, failed to augment the proliferative responses to concanavalin A by unfractionated splenocytes or splenic T cells from mice infected for 1 week. In addition, rIL-2 did not modulate the plaque-forming cell response to sheep erythrocytes by splenocytes from these same mice. However, at week 3, rIL-2 in concentrations ranging from 10 to 1,000 U/ml considerably augmented the proliferative response to concanavalin A and plaque-forming cell response to sheep erythrocytes by splenocytes from infected mice. Kinetics studies demonstrated that rIL-2 exerted maximal immunoregulatory activity when added on day 0 or 1 to cultures of splenocytes. In vivo administration of rIL-2, 200 to 20,000 U/day, for 10 days to normal and 3-week-infected mice did not alter the proliferative activity of splenocytes to concanavalin A; 200,000 U of rIL-2 per day actually depressed the proliferative responses of splenocytes from normal and infected mice. In vivo, rIL-2 did not modify delayed-type hypersensitivity responses to sheep erythrocytes or to histoplasmin by normal and infected mice. Moreover, treatment with rIL-2 in vivo did not reduce the number of Histoplasma CFU in spleens of mice. Thus, despite the immunoenhancing effect of rIL-2 in vitro, this lymphokine failed to exert similar effects in vivo.

Human monoclonal antibody. Construction of stable clones reactive with human breast cancer

A human clone was derived from fusion of a malignant cell line (Ball-1) and peripheral blood lymphocytes from a breast cancer patient in long-term remission. This clone, JDB1, was shown to be a genetically identifiable hybrid, expressing chromosomes unique to each of the parental cell types. The JDB1 clone produces IgG/lambda molecules which are extremely reactive with breast tumor cells, but do not bind to normal breast tissue or other types of malignant tissue. This hybrid was constructed without using the commonly accepted fusion technology which employs 8-azoguanine resistant HAT sensitive malignant fusion partners. Rather a selective fusion procedure was used in which a choice of the most efficient and effective malignant partner could be made prior to fusion. This approach was accompanied by stringent selection of patients as lymphocyte donors. This method has allowed for stable and vigorous growth of clones with a near constant amount of specific immunoglobulin production and a normal diploid chromosome number for over 3 years.

Evolution of inflammatory response and cellular immune responses in a murine model of disseminated blastomycosis

A reproducible model of disseminated blastomycosis was established in C57BL/6 mice by intravenous injection of 10(6) yeast-phase Blastomyces dermatiditis organisms. The infection progressed over 5 weeks to involve lungs, brains, superficial fascia, livers, and spleens of mice. By week 5, there was a greater number of organisms in lungs and brains than in livers and spleens. The tissue response in lungs, brains, and livers progressed from acute neutrophilic invasion before week 1 to pyogranuloma formation by week 5. Lymph nodes and spleens were remarkably spared. By week 5, infected mice became anergic to intradermal challenge with both specific Blastomyces antigen and a nonspecific antigen (sheep erythrocytes). At this time, the response to concanavalin A or phytohemagglutinin by splenocytes was markedly less than that of normal controls. Likewise, the plaque-forming cell response to sheep erythrocytes by splenocytes from infected mice was diminished. In coculture studies, splenocytes from 5-week-infected mice reduced the plaque-forming cell response by normal splenocytes. The development of this murine model should prove useful for elucidating the perturbations of immunoregulation associated with disseminated blastomycosis.

Chondromatous metaplasia in the human larynx

The finding of metaplastic fibroelastic cartilage in both vestibular folds of the larynx of an Orang-utan (Pongo pygmaeus) prompted the search for similar tissue in the same situation in 111 unselected human larynges removed at autopsy. Fibroelastic cartilage was found in both vestibular folds in three cases, being unilateral in a further four instances. The formation of this cartilage was preceded by the accumulation of acid mucopolysaccharide between fine collagen bundles within the vestibular fold followed by enlargement and alteration of the fibrocytes to resemble chondrocytes. These changes were found in 43 vestibular folds, and were bilateral in 10 cases.