Problems of myeloma in a community

The presenting features of 120 consecutive cases of myeloma diagnosed in a single unit were examined. Screening tests on routine laboratory samples increased the detection rate but did not significantly reduce the percentage of cases presenting with late stage disease. Morbidity was closely related to the incidence of bone involvement already present at diagnosis. About one fifth of cases had reported suspicious symptoms for some considerable time before further investigation was forthcoming. Almost half had 'benefitted' by having concurrent disease which often led to the discovery of myeloma at an early stage. These findings, together with the wide variety of symptomatology and few physical signs, stressed the critical importance of having a high index of suspicion and thus taking suitable blood samples without unnecessary delay.

Immunopathological study of spleen during Japanese encephalitis virus infection in mice

Following intraperitoneal inoculation, Japanese encephalitis virus replicated in peritoneal macrophages, appeared on day 3 in the splenic macrophages of the perifollicular region and later in cells of the periarteriolar lymphoid sheath (PALS) as shown by indirect immunofluorescence. Productive JEV infection was observed both in macrophages and T-cells. Morphological study of spleen during JEV infection revealed proliferative changes, with increased number of macrophages from day 3 p.i. in the perifollicular region followed by accumulation of polymorphonuclear leucocytes which reached a maximum on day 9 p.i. The T dependent areas were considerably enlarged by day 9 and gradually reduced in size by week 3. At later periods germinal centres appeared in the T independent area and were prominent by day 15. The cells containing virus antigen disappeared with the appearance of germinal centres, thus indicating the role of the latter also in virus clearance.

Intracoronary versus intravenous streptokinase in acute myocardial infarction

To assess the relative efficacy of coronary thrombolysis using intracoronary versus intravenous streptokinase, 32 patients with acute myocardial infarction were randomly assigned to receive intracoronary (n = 17) and intravenous streptokinase (n = 15). All patients underwent selective coronary arteriography before and after administration of streptokinase by either route within 4 hours of the onset of symptoms. Intravenous streptokinase was given as 750,000 units over 30 minutes, while a mean dose of 180,000 units was required for thrombolysis in the group having intracoronary delivery. Recanalization occurred in 71.4% (10 of 14) of patients receiving streptokinase, by the intracoronary group in contrast to only 25% of patients (3 of 12) who received the drug intravenously (P less than 0.05). Spontaneous thrombolysis was seen in 17.6% and 20% of the patients in the groups having intracoronary and intravenous delivery, respectively. Bleeding complications were few in both groups. Thus, when baseline coronary arteriography is performed, recanalization with intracoronary streptokinase is more effective in the treatment of acute myocardial infarction than intravenous streptokinase.

Quantitative thallium-201 single photon emission computed tomography after oral dipyridamole for assessing the presence, anatomic location and severity of coronary artery disease

The objective of this investigation was to determine whether analysis of thallium-201 images as detected by quantitative single photon emission computed tomography after a single high oral dose of dipyridamole (300 mg) would accurately detect the presence of coronary artery disease and the anatomic location of the individual stenosis. Analyses were performed on 100 patients who concomitantly underwent diagnostic coronary arteriography and myocardial imaging. Tomographic myocardial perfusion defects were quantified using computer-generated polar maps. Eighty-four patients had significant coronary artery disease defined as greater than 50% luminal diameter stenosis. The sensitivity for detecting patients with coronary disease was 92% overall, 89% in patients without previous myocardial infarction and 97% in those with prior infarction. The technique had a sensitivity of 80, 87 and 51% for localizing coronary artery stenosis of the left anterior descending, the right coronary and the left circumflex artery, respectively. The corresponding specificity was 84, 92 and 92%. Furthermore, the presence of severe (greater than or equal to 70%) multivessel disease was identified with a sensitivity of 79% and a specificity of 87%. In conclusion, quantitative thallium-201 single photon emission computed tomography after oral dipyridamole has high sensitivity and specificity for diagnosing the presence of coronary disease, ascertaining the location of stenosed vessels and identifying the presence of multivessel disease.

A double-blind study of diflunisal and codeine compared with codeine or diflunisal alone in postoperative pain

A double-blind, randomized, parallel-group study compared the analgesic efficacy of a single oral dose of 500 mg diflunisal, 60 mg codeine, 500 mg diflunisal plus 60 mg codeine given as separate agents, and placebo in 161 patients with moderate to severe postoperative pain. Standard subjective measures were used to evaluate analgesia. Eight-hour sum of pain intensity differences and total pain relief scores for all active treatments were significantly better than were those for placebo (p less than 0.05). Diflunisal plus codeine performed the best followed by diflunisal, codeine, and placebo. Diflunisal plus codeine was better than placebo from 1 1/2 to 8 hours (p less than 0.01), better than codeine from 1 1/2 to 6 hours (p less than 0.05), and better than diflunisal alone from 1/2 to 1 1/2 hours (p less than 0.05) for most measures of analgesia. Factorial analysis demonstrated a significant early codeine effect and a significant diflunisal effect throughout. No significant treatment group differences were observed regarding adverse effects. Our data demonstrate that diflunisal plus codeine is generally well tolerated and provides analgesia superior to that of diflunisal or codeine alone in the treatment of moderate to severe postoperative pain.

Clinical significance of perfusion defects by thallium-201 single photon emission tomography following oral dipyridamole early after coronary angioplasty

The clinical significance of myocardial perfusion defects present early after angiographically successful percutaneous transluminal coronary angioplasty was assessed in 53 patients using thallium-201 single photon emission computed tomography combined with pharmacologic vasodilation induced by a large dose (300 mg) of orally administered dipyridamole. Myocardial tomographic images were obtained at a mean of 20 +/- 6 h (SD) before and 2.9 +/- 2.7 days after angioplasty. Before angioplasty, 15 (28%) of the 53 patients developed angina after dipyridamole administration, in contrast to only 3 (7.5%) of 40 patients after angioplasty (p less than 0.001). The mean percent luminal area stenosis decreased from 93 +/- 6% before angioplasty to 34 +/- 17% after angioplasty (p less than 0.001). Myocardial perfusion defects, present in 49 (93%) of the 53 patients before angioplasty, were reversible in 44 patients (83%), all of whom underwent dilation of arteries supplying the ischemic areas. After angioplasty, 26 (65%) of 40 patients had no ischemic defects, whereas 14 (35%) of the patients still had an ischemic defect in the vascular territory of the dilated artery. After a mean follow-up period of 21.7 months, 13 (33%) of 39 patients developed restenosis, 10 of whom had an ischemic defect early after angioplasty. Restenosis developed in 10 (71%) of 14 patients with an ischemic defect after angioplasty, but in only 3 (11.5%) of the patients without an ischemic defect (p = 0.007). In conclusion, thallium-201 tomography after oral dipyridamole affords convenient assessment of the physiologic significance of coronary stenosis present before angioplasty and the residual stenosis after angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual complication of left ventricular pseudoaneurysm: hemoptysis

Left ventricular aneurysm is a common sequela of anterior myocardial infarction. At the time of coronary artery bypass grafting, resection of this aneurysm is frequently undertaken to alleviate symptoms of heart failure and/or refractory ventricular tachycardia. Complications related to aneurysmectomy are uncommon. We describe an unusual patient who presented with hemoptysis related to the formation of a pseudoaneurysm which communicated with the lung parenchyma. The etiology of the pseudoaneurysm formation was an indolent, slow-growing infection.

Unstable angina secondary to left main coronary thrombus extending from prosthetic aortic valve

Embolic complications due to prosthetic heart valves are common. The present report documents a left main coronary artery thrombus extending from a Starr Edward's aortic ball valve prosthesis 22 years after its placement. It resulted in unstable angina and a small myocardial infarction. This rare complication illustrates the importance of adequate anticoagulation.

Role of polyamines in the synthesis of RNA in mycobacteria

All three polyamines - putrescine, spermidine and spermine stimulated the activity of mycobacterial RNA polymerase in vitro although the concentration required for maximal stimulation was different for each of the amines. Spermidine and spermine showed a biphasic effect on the enzyme activity. Stimulation of RNA synthesis by spermidine occurs only at higher DNA template/enzyme ratio. Spermidine stimulates RNA synthesis by acting on the elongation phase of RNA synthesis but it had no effect on initiation phase. Addition of mycobacterial RNA to the assay mixture resulted in the inhibition of RNA polymerase activity and this inhibition could be reversed by spermidine suggesting that spermidine stimulates transcription by binding to nascent RNA and thus destabilizing the short DNA-RNA hybrid region.

In vivo assessment of vascular dilatation during percutaneous transluminal coronary angioplasty

Previous studies of the mechanism of percutaneous transluminal coronary angioplasty used either postmortem specimens or animal models. To characterize the process of vascular dilatation in vivo, a system was devised for recording the instantaneous pressure-volume changes in the angioplasty balloon during inflation within the stenosed artery. The pressure-volume patterns obtained were compared with those observed in vitro with the balloon inflated in materials whose properties simulate stretching (Silastic tubing), compaction (styrofoam) and cracking (dry macaroni). Of 48 narrowings in 46 patients, a pressure-volume pattern of stretching was observed in 56%, compaction in 27% and cracking in only 17%. Of lesions manifesting a stretching pattern, 85% were longer than 5 mm cr had visible calcium deposits, whereas those that compacted were shorter and lacked calcium deposits. Both of these pressure-volume patterns were associated with a successful clinical outcome. Of 8 lesions exhibiting a cracking pattern, 6 showed dissection angiographically; 3 of these resulted in vessel occlusion.

Dissociation between global and regional systolic and diastolic ventricular function during coronary occlusion and reperfusion

Indexes of global ventricular function such as the ejection fraction (EF) and the peak diastolic filling rate (PDFR) are often used to assess the effects of coronary recanalization in patients with myocardial infarction. In this investigation we assessed the relationship between these global indexes and directly measured indexes of regional function during 15 minutes of coronary occlusion followed by 120 minutes of reperfusion in 22 open-chest dogs. A computerized nuclear cardiac probe was used to assess EF and PDFR. Indexes of regional function were measured by Doppler ultrasonic wall-thickening probes. During coronary occlusion, paradoxical systolic thinning occurred and the EF and PDFR decreased an average of 31.6% and 24.4%, respectively. During reperfusion the EF and PDFR improved rapidly and at 60 minutes were similar to baseline. Systolic wall thickening improved more gradually and remained abnormal throughout reperfusion. Likewise, indexes of diastolic function (mean rate to half end-diastolic thinning and late diastolic thinning fraction) recovered slowly and remained abnormal throughout reperfusion (78% and 69.7%, respectively). The correlation between the rate of change of global and regional function was poor during both coronary occlusion and reperfusion. Thus, during coronary occlusion the global and regional indexes of ventricular function undergo directionally similar changes. However, during coronary reperfusion the global indexes do not reflect the slow recovery of the stunned myocardium.

Determination of aspirin by pre-column transacetylation reaction of 3-aminophenol and reversed-phase high-performance liquid chromatography: simultaneous determination of aspirin, acetaminophen, and caffeine

The accuracy of the measurement of aspirin by high-performance liquid chromatography (HPLC) is reduced by its hydrolysis into salicylic and acetic acids during sample preparation. The ready and quantitative transacetylation of 3-aminophenol by aspirin, giving 3-hydroxyacetanilide (which is stable), has been utilized as a pre-column reaction for the determination of aspirin either alone or in the presence of acetaminophen and caffeine by reversed-phase HPLC.

Brief periods of myocardial ischemia followed by reperfusion: a model in the dog of sudden cardiac death in humans

Most experimental interest has focused on the electrophysiologic mechanisms which may underlie sudden death. The purpose of the present study was to develop a model in the dog where ischemia would produce not just ventricular fibrillation but also histologic abnormalities similar to those previously reported in sudden death in humans. First, the collateral blood flow to a portion of the ventricle was surgically abolished and then the arterial blood supply to this region was interrupted for 15 minutes after which nutrient flow was restored for 30 minutes. If the animal survived, this cycle was repeated up to seven times. Thirty-six animals were studied: 15 controls (Group A) survived an average of 1.75 +/- 0.8 cycles (mean +/- SD); 11 others (Group B) received a loading dose of sodium verapamil and survived 3.7 +/- 1.8 cycles while 10 (Group C) received a continuous infusion as well as the loading dose of sodium verapamil and survived 4.4 +/- 2.6 cycles--the difference between each group being significant (p less than 0.05). Four animals in Group C survived all 7 cycles; out of the other 32, 27 fibrillated just after reperfusion and the rest during ischemia. Histological examination revealed small foci of contraction band necrosis widely interspersed amongst large areas of morphologically normal tissue. The beneficial effect of verapamil and the histologic findings suggest cellular calcium overload may be important in the genesis of the fatal arrhythmias produced by reperfusion.

Spermine decreases peripheral vascular resistance in the dog and relaxes the isolated aorta of the guinea pig

Polyamines, found in all nucleated cells, have been shown to relax uterine, gastrointestinal, and respiratory tract smooth muscle. When parenterally administered to the rat or dog they cause hypotension. To determine the range of the relaxing effect of polyamines on smooth muscle and the mechanism of the hypotensive effect anaesthetised dogs were infused with increasing intravenous bolus doses of spermine while cardiovascular measurements were made. At doses of greater than or equal to 2 mg X kg-1 spermine a reversible hypotensive effect was produced that is accounted for by changes in peripheral vascular resistance. It is unlikely that this effect was due to the known propensity of polyamines to release histamine because the hypotensive action of 2 mg X kg-1 spermine was unaltered by pretreatment with the H1 and H2 blockers, diphenhydramine and cimetidine. Evidence that the spermine effect is not mediated by circulating agents was shown by the ability of spermine to relax the precontracted guinea pig isolated aorta. These results in vascular smooth muscle may be added to those in other types of smooth muscle shown to be relaxed by polyamines; the polyamine effect on smooth muscle may be ubiquitous. These data also raise the possibility that changing concentrations of tissue polyamines may play a role in the regulation of tissue blood flow.

Effectiveness of bevantolol in the treatment of hypertension: once-daily versus twice-daily evaluation of home blood pressure measurements

Two multicenter, double-blind, placebo-controlled studies were conducted to determine in patients with hypertension the oral dose of bevantolol that would effectively reduce home diastolic blood pressure to less than 95 mm Hg. The two studies differed only in once-daily or twice-daily dose administration. In the 125 patients evaluated, the mean decreases in home diastolic blood pressure were significantly greater in patients receiving 100 to 400 mg/day of bevantolol (8 to 10 mm Hg) than in patients receiving placebo (2 to 3mm Hg) (p less than 0.05). Bevantolol administered once daily or twice daily was equally effective in the management of hypertension and was well tolerated in the doses studied.

Effect of inflation pressures on coronary angioplasty balloons

It is a common conception that the balloons used in percutaneous transluminal coronary angioplasty will inflate to a certain designated diameter and maintain this diameter over the wide range of inflation pressures. With use of an optical magnification system, the diameters of multiple angioplasty dilating catheters made of polyvinyl chloride (USCI) and polyethylene (Advanced Cardiovascular System, Inc.) were measured with designated balloon diameter sizes of 2.0 to 3.7 mm. All balloons had a linear increase in diameter over a range of pressures from 2 to 10 atm. The average increase in diameter over this pressure range was 15% (range 7 to 18%). Polyvinyl chloride balloons reached their specified diameter at less than 5 atm and exceeded it at higher inflation pressures. Polyethylene balloons reached their specified diameter at 8 to 10 atm, and were below specified diameters at lower pressures. There was slight variation in size and only a minimal difference in compliance between balloons of the same material and size. A given balloon achieved the same diameter at a given pressure even after multiple inflations and maintained a stable diameter during prolonged inflations.

Gastric cancer: complete chemotherapy response in an elderly woman: current status of treatment

Complete response to chemotherapy treatment was achieved in an 86-year-old woman with extensive metastatic gastric carcinoma. Thirty months after the initiation of treatment, the patient continues to be in complete remission. Chemotherapy consisted of a modified FAM regimen (5 FU, mitomycin C, and doxorubicin) for 1 year. Current chemotherapy recommendations for gastric carcinoma as well as the medical, psychosocial, and ethical considerations for chemotherapy treatment in the elderly are reviewed.

Hypertension in hypoglycemic diabetics treated with beta-adrenergic antagonists

To evaluate the response during insulin-induced hypoglycemia, diabetics treated with relatively selective or nonselective beta-adrenergic blocking agents were studied. Placebo, atenolol (100 mg/day), and propranolol (80 mg b.i.d.) were administered to 12 insulin-treated diabetics for 1 week in a double-blind, randomized, crossover fashion with a 2-week washout between treatments. Sufficient intravenous insulin (0.2-0.6 units/kg) was administered to decrease plasma glucose 68% from the basal level or to less than 60 mg/dl within 90 minutes. Blood pressure changes at the nadir of plasma glucose were +15.2/-9.9 mm Hg for placebo, +27.9/0 mm Hg for atenolol, and +38.8/+14.3 mm Hg for propranolol. Diastolic blood pressure changes induced by propranolol were significantly different from those induced by atenolol (p less than 0.01) and placebo (p less than 0.01), and systolic pressure changes were significantly different (p less than 0.02) between propranolol and atenolol. Mild seizures developed in two patients treated with propranolol. Their blood pressure changes at the plasma glucose nadir were +56/+22 and +86/+31 mm Hg. Other symptoms of hypoglycemia were more frequent during beta-blocker than during placebo treatment. Differences in response may be related to the relatively selective adrenergic blocking effect of these drugs.

Hypertension in hypoglycemic diabetics treated with beta-adrenergic antagonists

To evaluate the response during insulin-induced hypoglycemia, diabetics treated with relatively selective or nonselective beta-adrenergic blocking agents were studied. Placebo, atenolol (100 mg/day), and propranolol (80 mg b.i.d.) were administered to 12 insulin-treated diabetics for 1 week in a double-blind, randomized, crossover fashion with a 2-week washout between treatments. Sufficient intravenous insulin (0.2-0.6 units/kg) was administered to decrease plasma glucose 68% from the basal level or to less than 60 mg/dl within 90 minutes. Blood pressure changes at the nadir of plasma glucose were +15.2/-9.9 mm Hg for placebo, +27.9/0 mm Hg for atenolol, and +38.8/+14.3 mm Hg for propranolol. Diastolic blood pressure changes induced by propranolol were significantly different from those induced by atenolol (p less than 0.01) and placebo (p less than 0.01), and systolic pressure changes were significantly different (p less than 0.02) between propranolol and atenolol. Mild seizures developed in two patients treated with propranolol. Their blood pressure changes at the plasma glucose nadir were +56/+22 and +86/+31 mm Hg. Other symptoms of hypoglycemia were more frequent during beta-blocker than during placebo treatment. Differences in response may be related to the relatively selective adrenergic blocking effect of these drugs.

Biclonal IgA and IgM gammopathy in lymphocytic lymphoma

We report the case of a 76-year-old white man with a diffuse, well-differentiated lymphocytic lymphoma at the base of his tongue. Although serum electrophoresis, immunoelectrophoresis, and immunofixation showed he had a biclonal IgA kappa and IgM kappa gammopathy, biopsy of the tumor showed a positive immunoperoxidase response only for IgM kappa. The biclonal pattern persisted after chemotherapy, despite shrinkage of the tumor mass. The association of IgA and IgM appears to be the least frequent combination of separate biclonal immunoglobulins, the clinical course of such patients being more often that of lymphoma or macroglobulinemia than of myeloma. However, the symptomatology can be highly variable, as our case uniquely demonstrates.

Biclonal IgA and IgM gammopathy in lymphocytic lymphoma

We report the case of a 76-year-old white man with a diffuse, well-differentiated lymphocytic lymphoma at the base of his tongue. Although serum electrophoresis, immunoelectrophoresis, and immunofixation showed he had a biclonal IgA kappa and IgM kappa gammopathy, biopsy of the tumor showed a positive immunoperoxidase response only for IgM kappa. The biclonal pattern persisted after chemotherapy, despite shrinkage of the tumor mass. The association of IgA and IgM appears to be the least frequent combination of separate biclonal immunoglobulins, the clinical course of such patients being more often that of lymphoma or macroglobulinemia than of myeloma. However, the symptomatology can be highly variable, as our case uniquely demonstrates.

Cyanate binding to the ferric heme octapeptide from cytochrome c. A model for anion binding to high spin ferric hemoproteins

Equilibrium constants for the binding of cyanate to the ferric heme c octapeptide in 50% ethylene glycol, 50% aqueous buffer were measured spectrophotometrically. Equilibrium constants measured at several temperatures from -20 degrees C to 0 degrees C exhibited an apparent van't Hoff relationship yielding thermodynamic values of delta Ho = -1.3 X 10(3) +/- 0.9 X 10(3) J/mol (-3.1 X 10(2) +/- 2 X 10(2) cal/mol), delta So = -3 +/- 3 J/K X mol (-0.6 +/- 0.8 cal/K X mol). The equilibrium constant for cyanate binding at 25 degrees C and pH 7.4 is 1.21 which is approximately 2 to 3 orders of magnitude lower than that observed for cyanate binding to methemoglobin and metmyoglobin. Krel, the ratio of the hemoprotein to model heme octapeptide binding constants, for NCO- is smaller than Krel for N3- suggesting that hydrogen bonding between the terminal ligand atoms and the distal histidine in hemoglobin and myoglobin does not contribute to the increased protein ligand stabilization observed for these anions relative to the model. A donor-acceptor interaction between the distal histidine and the electrophilic middle atoms of these bound ligands is proposed.