Emergency thoracotomy for thoracic trauma in the accident and emergency department: indications and outcome

To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.

Effect of motion outside the field of view on functional MR

PURPOSE

To evaluate the effect of objects moving outside the field of view on functional MR imaging.

METHODS

Echo-Planar image sequences were acquired in the sagittal plane of a stationary phantom or of the head of a volunteer subject while a second phantom was moved periodically outside the field of view. The signal intensity changes in each pixel within the field of view were measured.

RESULTS

Movement of the phantom outside the field of view produced signal intensity changes in the field of view that equaled or exceeded typical functional activation without the latency that characterizes activation. The greatest changes occurred at the bottom and top edges in the phantom and at the interfaces in the head.

CONCLUSION

If temporally correlated with the performance of a task, movement of objects or tissues outside the field of view may produce artifactual changes in signal intensity. The artifactual signal intensity changes were characterized by their location, greater magnitude, and more rapid rise to maximum than seen with typical "activation."

Organic acids interfere in the measurement of carbon dioxide concentration by the Kodak Ektachem 700

A significant discrepancy was noted in our laboratory between the total plasma carbon dioxide concentration measured by the Kodak Ektachem 700 and the bicarbonate concentration derived from the Corning 170 pH/Blood Gas analyser in an 8-day-old patient. The concentration of total carbon dioxide was 18 mmol/L while the derived bicarbonate was 13 mmol/L. The patient was eventually diagnosed as maple syrup urine disease. This finding led us to examine the effect of various organic acids on the measurement of carbon dioxide by the Ektachem 700. Several interfered significantly. Clinicians should be aware that when organic acid concentrations are increased, the Ektachem 700 total carbon dioxide result may be falsely raised.

Protooncogene amplification and tumor ploidy in human ovarian neoplasms

DNA from 24 ovarian tumors, including 16 carcinomas, was examined for amplification of the proto-oncogenes c-myc, int-2, and rc-erbB-2. All cases of carcinoma were also examined by flow cytometry for DNA ploidy and cell cycle analysis, and eight cases of carcinoma were examined for estrogen and progesterone receptors. Protooncogene amplification was not detected in the DNA of benign ovarian neoplasms, or of ovarian carcinomas with low malignant potential. Amplification of c-myc was detected in six of 12 cases of invasive carcinoma, int-2 amplification was present in one case, and c-erbB-2 amplification was not detected in any case. Among the seven cases evidencing protooncogene amplification, three cases showed aneuploidy in tumor DNA, while four showed diploidy. Two cases which showed aneuploidy in tumor DNA did not demonstrate any degree of protooncogene amplification. Protooncogene amplification was frequently associated with morphologic nuclear anaplasia and high mitotic count. Six of the seven cases demonstrating c-myc or int-2 were of the serous type or showed some degree of serous differentiation, while none of the four cases of purely mucinous carcinoma had evidence of amplification. While the total number of cases in the study was limited, it would appear from the trend demonstrated by the data that protooncogene amplification (particularly c-myc) may be involved in the pathogenesis of aggressive common epithelial tumors of the ovary.

Obesity and mortality in the Lipid Research Clinics Program Follow-up Study

Using data from the Lipid Research Clinics Program for 1972-1983, the study presented here examined weight history and two indices of obesity: the body mass index (BMI) and the triceps skinfold (TSF) thickness. Cox regression analyses with and without adjustment for cardiovascular disease risk factors revealed a significant (p less than 0.05) quadratic association between BMI and all-causes mortality among men, but not women, after an average 8.4 years of follow-up; mortality was relatively high at both extremes of the BMI distribution. The association was stronger among smokers compared with nonsmokers, and it was apparent among male normotensives, but not hypertensives. All TSF-mortality associations and BMI associations with cancer and coronary heart disease mortality were weak and nonsignificant. Among men, per cent weight change in adulthood showed a significant inverse association with all-causes and cancer mortality. Because BMI and weight history were significantly associated with mortality after adjustment for other risk factors, they appear to be independent predictors of mortality among men.

Unknown syndrome: pachygyria, joint contractures, and facial abnormalities

A male infant, the offspring of a father-daughter mating, is described. He had a lethal condition consisting of brachycephaly, large fontanelles, a flat face, a small nose with thin nares, hypertelorism, small ears with cystic pinnae, camptodactyly, talipes equinovarus, and hypoplastic lungs and kidneys. The brain was very short in the anterior-posterior diameter with simplified broad convolutions (a form of pachygyria).

Lean on me

Our booklet on the role of the mentor was written to support and encourage newly qualified nurses in their new-found relationship with learner nurses.

A clinical diagnostic model for the assessment of asbestosis: a new algorithmic approach

Asbestosis, one of the pneumoconioses that is defined by a set of clinical, radiographic, and pathologic findings, occurs as a result of exposure to asbestos fibers. Several approaches have attempted to describe the presence, progression, or extent of asbestosis. However, these approaches have attempted to describe the presence, progression, or extent of asbestosis. However, these approaches have limitations or lack correlations with other diagnostic modalities. We propose a comprehensive clinical diagnostic model that uses the sensitivities and specificities of the various clinical, radiographic, and pathologic findings to generate a set of "likelihood numbers." These likelihood numbers, contribute to the calculation of a value that can indicate the probability of asbestosis. The clinical diagnostic model is heuristic in that a specific feature supportive of the diagnosis of asbestosis may be tested as to its sensitivity and specificity, and new features may be added to the model. The model also indicates how probabilistic a given set of findings is in the diagnosis of asbestosis and suggests what additional data may make the diagnosis more or less statistically probable. Regarding the radiologic considerations of asbestosis, the strength of the clinical diagnostic model is that it is capable of supporting a diagnosis of asbestosis in the presence of a normal chest radiograph and, conversely, may reject the diagnosis of asbestosis despite the radiographic finding of pulmonary fibrosis.

Cyclic seasonal variation in plasma lipid and lipoprotein levels: the Lipid Research Clinics Coronary Primary Prevention Trial Placebo Group

Seasonal plasma lipid and lipoprotein cycles were studied in 1446 hypercholesterolemic 35-59 year-old men followed for 7 years as the placebo group of the Lipid Research Clinics (LRC) Coronary Primary Prevention Trial (CPPT). Separate periodic time series were calculated for each study participant; mean parameter estimates were obtained by vector algebra. Highly significant (p less than 0.001) synchronous sinusoidal seasonal cycles, peaking in the first month of winter, were demonstrated for plasma levels of total (TOT-C), low-density lipoprotein (LDL-C), and high-density lipoprotein (HDL-C) cholesterol. Their mean seasonal changes (nadir to zenith) were 7.4, 6.4, and 0.8 mg/dl, respectively. An irregular but statistically significant seasonal pattern was also observed for plasma triglyceride (TG) levels, with peak levels in the autumn. The variation of these seasonal effects among subgroups and geographic locales and their correlation with seasonal weight and dietary patterns yielded few clues as to their underlying etiologic mechanisms.

Seasonal cholesterol cycles: the Lipid Research Clinics Coronary Primary Prevention Trial placebo group

Seasonal variation of plasma cholesterol levels was studied in 1446 hypercholesterolemic 35- to 59-year-old male participants in the Lipid Research Clinics Coronary Primary Prevention Trial placebo group. Each man's serial cholesterol data, obtained at bimonthly intervals for 2.0 to 6.5 years, were analyzed as a separate periodic time series, and distributions of cycle zeniths and amplitudes were calculated. A highly significant (chi 2= 706, 2 degrees of freedom) seasonal effect, 7.4 mg/dl higher on December 30 than on June 30, was found. This effect was similar among the 12 LRC centers, including such disparate climates as those of Minneapolis and San Diego, and tended to be larger in the southern centers. Its magnitude was independent of baseline levels of plasma cholesterol and other baseline characteristics. Observed seasonal differences in weight and diet explained less than one-third of the seasonal variation in plasma cholesterol levels. Plasma low- and high-density lipoprotein cholesterol levels, analyzed similarly, also showed significant synchronous seasonal cycles. Plasma triglyceride levels showed a weaker irregular seasonal pattern, highest in midsummer and late autumn and lowest in spring. The etiologies and mechanisms for these seasonal patterns remain largely unknown.

The dexamethasone suppression test and prediction of outcome in patients receiving ECT

Twenty-six in-patients satisfying DSM-III criteria for major depressive episode were assessed using the Newcastle Diagnostic and ECT Predictor Scales and the dexamethasone suppression test (DST), prior to commencing a course of electroconvulsive therapy (ECT). The Newcastle ECT Predictor Scale was successful in predicting both immediate outcome and outcome over the 6 months following ECT; the DST was unsuccessful in predicting either immediate or 6-month outcome.

DNA-mediated transfer of cAMP resistance in CHO cells

Chinese hamster ovary (CHO) strain 10215 carries a dominant mutation which confers resistant to cAMP by virtue of an altered catalytic subunit of the cAMP-dependent protein kinase (Evain et al., 1979). This mutation was transferred to wild-type CHO cells by DNA-mediated gene transfer. Based on the absence of cAMP growth inhibition, seven transformant colonies were isolated. One of these, 11586, was studied in detail. This transformant showed the same phenotype as the mutant, including resistance to the morphological changes and growth inhibitory effects of 1 mM 8-Br-cAMP, reduced total cAMP dependent protein kinase activity and lowered sensitivity of the kinase to cAMP activation. When the cAMP-dependent protein kinase was fractionated on a DEAE-cellulose column, the transformant was lacking in type II cAMP dependent protein activity, to the same degree as the mutant. The transformant and mutant, but not wild-type cells, also failed to phosphorylate a 52,000-dalton protein in a cAMP-dependent manner. These characteristics support the conclusion that the gene for the mutant cAMP-dependent protein kinase has been transferred. The ability to transfer this gene by DNA-mediated transfer suggests that this methodology may be useful for the molecular isolation of the gene encoding the catalytic subunit of cAMP-dependent protein kinase.

DNA-mediated gene transfer of a mutant regulatory subunit of cAMP-dependent protein kinase

We have used DNA-mediated gene transfer of genomic DNA to introduce into wild-type Chinese hamster ovary (CHO) cells a mutant gene that confers resistance to the growth inhibitory effect of cAMP. This dominant mutation in CHO cell line 10248 is responsible for an alteration in the RI subunit (RI*) of the type I cAMP-dependent protein kinase (Singh, T. J., Hochman, J., Verna, R., Chapman, M., Abraham, I., Pastan, I.H., and Gottesman, M.M. (1985) J. Biol. Chem. 260, 13927-13933). The transformant 11564 which was studied in detail, has the same characteristics as the original mutant 10248 including continued growth in medium containing 8-Br-cAMP, an increase in the Ka for cAMP activation of the kinase, a greatly reduced amount of type II protein kinase activity, an altered incorporation of the photoaffinity label 8-N3[32P]cAMP into the RI* subunit of PKI, and an absence of cAMP-dependent phosphorylation of a Mr = 52,000 protein in intact cells. In addition, analysis of the DNA of the transformant indicates the presence of an increased amount of DNA for the RI gene. These results are consistent with the transfer of a mutant gene for the RI* subunit of the cAMP-dependent protein kinase and its phenotypic expression in the transformant and also support the hypothesis that the mutation responsible for the defect in cell line 10248 is due to an alteration in the gene for RI.

Progressive supranuclear palsy, computed tomography, and response to antiparkinsonian drugs

Three patients with progressive supranuclear palsy demonstrated atrophy of the midbrain, pons, cerebellum, and cerebral hemispheres by computed tomography with horizontal, sagittal, and coronal reconstruction. Benztropine therapy resulted in improvement of speech and gait without significantly affecting the vertical gaze palsy.

Morphometric analysis of volumes and surface areas in membrane compartments during endocytosis in Acanthamoeba

Stereologic analysis was made of cell surface membrane (PM) and two interrelated cytoplasmic membrane systems, the vacuole membranes (VM) and small vesicle membranes (SVM). Volumes and surface areas of the three membrane compartments were measured during steady-state pinocytosis, when membrane recycling is rapid, and during phagocytosis, when a shift to a lower rate of membrane uptake by endocytosis occurs (B. Bowers, 1977, Exp. Cell Res. 110:409). Total membrane area in the three compartments was 3.2 micrometers 2/micrometers 3 of protoplasmic volume and was constant throughout the experiments. In pinocytosing cells, 32% of the membrane was in the PM, 25% in the vM, and 43% in the SVM. The vacuole compartment occupies approximately 20% of the total cell volume, and the small vesicle, approximately 3%. As the endocytic uptake of membrane from the surface decreased, there was an increase in PM area and a marked decrease in SVM area. The VM area remained constant even though "empty" vacuoles were almost completely replaced by newly formed phagosomes within 45 min. This demonstrates directly a rapid flux of membrane though this compartment. A model, taking into consideration these and other data on Acanthamoeba, is proposed to account for the observed membrane shifts. The data suggest that the vacuolar (digestive) system of Acanthamoeba is central to cellular control of endocytosis and membrane recycling.

Inherited disorders of 3-methylcrotonyl CoA carboxylation

The clinical course of 4 patients who had reduced activities of 3-methylcrotonyl CoA carboxylase (also called 3-methylcrotonylglycinuria) is described. Two children presented with a metabolic acidosis, one in the neonatal period and the other with episodes of acidosis that started in the second year of life. In the other 2 children neurological symptoms were prominent, one having infantile spasms and the other developmental regression with a skin rash and alopecia. Three of the children responded well to oral biotin and dietary protein restriction but the fourth, despite a biochemical response to biotin, has a severe neurological handicap. The clinical presentation of inborn errors of 3-methylcrotonyl CoA carboxylase is variable. Metabolic acidosis may not be conspicuous and instead neurological features may predominate.

Management of external gastrointestinal fistulas with glucose and lipids

Thirty-one patients with 35 external gastrointestinal fistulas were initially managed conservatively with total parenteral nutrition. Patients received the centrally infused glucose system or the peripherally infused lipid system, or both systems, in sequence. Eighteen of the fistulas closed spontaneously, and nine patients died. Eleven of the 15 fistulas managed exclusively with the lipid system closed spontaneously. The results of this retrospective study attest, in general, to the value of total parenteral nutrition and, in particular, to the value of the lipid system which appears equally effective, at least in a subset of patients with fistulas.

A prepaid medical plan. Cost, use, and effects in a retirement home

A model experience of a prepaid medical plan for a group of people is analyzed. No-barrier cost and physician access lead to altered use characteristics. Among these are increased physician, nurse, and nursing home use, and decreased hospital use. The overall cost is increased. Any comprehensive health-care plan that would propose comprehensive first-dollar coverage would likely encounter similar use characteristics.