Unexplained Cardiac Arrest During Closure of Craniotomy: Case report and review of literature

Hypotension and bradycardia after application of suction to a subgaleal drain, or stimulus inside or outside the skull, have been reported in the medical literature. The commonly reported occurrence is stimulation of the Trigeminal nerve along its distribution and is the main factor that sets off the whole reflex arc through the Vagus nerve ending in a series of serious hemodynamic changes that institute severe bradycardia, asystole and severe hypotension. Another less common but possible patho logy caused by a suction drain is Pseudo-Hypoxic Brain Swelling (PHBS). We report a case of transient cardiac arrest after the application of theatre suction to a subgaleal drain at the closure of an uneventful craniotomy and discuss the possibilities as well as review the literature.

The relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality

BACKGROUND

Prediction of in-hospital mortality may direct hospital resources towards those patients most at risk. A number of single domain risk instruments have been developed, indicating that functional status, nutritional assessment, and severity of illness individually predict in-hospital mortality. The interaction among these predictors is less well described.

OBJECTIVE

To determine the relationship of functional status, nutritional assessment, and severity of illness to in-hospital mortality.

DESIGN, SETTING, SUBJECTS

Cohort study of 1712 consecutive admissions over a one year period to an Internal Medical Service at a tertiary university teaching hospital.

MAIN OUTCOME MEASURES

Death during hospital admission.

RESULTS

Dependency in activities of daily living (OR = 3.37, 95% CI 1.78 to 6.37, p = 0.0002) and body mass index less than 20 (OR = 2.38, 95% CI 1.20 to 4.74, p = 0.01) predicted in-hospital mortality after adjusting for nutritional risk assessment, and severity of illness score.

CONCLUSIONS

Impairment in functional status and low body mass index produce the best predictors of inhospital mortality, after adjusting for nutritional risk and severity of illness score. Among these factors, functional impairment may be amenable to correction.

Urinary bladder bilharziasis as a cause of impaired bladder muscle contractility

In an attempt to evaluate the effect of bilharziasis on bladder contractility as a factor in the genesis of voiding disorders, 44 cases of bilharzial bladder neck obstruction diagnosed using traditional methods (symptomatological, radiographic, and endoscopic) were subjected to complete urodynamic evaluation (flowmetry, cystometry, pressure/flow study, and stop-flow test). Their parameters were compared with those of 28 patients with urodynamically obstructed benign prostatic hyperplasia and 8 nonsymptomatic controls. Contractility parameters (isometric detrusor pressure, maximum estimated flow rate, detrusor power at maximum flow) were calculated for the studied cases and their distribution according to the Schafer pressure/flow diagram was evaluated. Bladder biopsy including the detrusor was evaluated in all 72 patients. Poor bladder contractility associated with an extensive bilharzial effect on the detrusor muscle was found to be the major abnormality in 20 of 44 patients with presumed bilharzial bladder neck obstruction with no evidence of urodynamic outflow obstruction. We believe such a workup is essential in cases of suspected obstruction associated with bilharziasis to throw light on the pathophysiology of the voiding disorders, avoid unnecessary surgery, and provide a better prognosis.

Differential cognitive effects of colloid cysts in the third ventricle that spare or compromise the fornix

A series of twelve cases, all of whom had received surgery for the removal of a colloid cyst in the third ventricle, was examined on a series of memory tests. The only consistent predictor of poor memory performance that could be detected from MRIs was the presence of bilateral interruption of the fornix, which occurred in three of the subjects. Although these three cases were poor on tests of learning and recall, there was evidence that recognition was less impaired. The subjects were also tested on a set of recognition and concurrent discriminations that closely matched tests given to non-human primates. Clear parallels were found between the apparent effects of fornix damage in these clinical cases and those observed following more selective surgery in non-human primates. These findings not only indicate that fornix damage is sufficient to induce anterograde amnesia but also support the validity of recent animal tests that are thought to capture aspects of episodic memory.

Aicardi-Goutières syndrome: an expanding phenotype

The Aicardi-Goutières syndrome (AGS) is an autosomal recessive progressive encephalopathy associated with basal ganglia calcification, white-matter abnormality, cerebro-spinal fluid (CSF) pleocytosis and elevated CSF interferon alpha (IFN alpha). Two brothers of consanguineous parents who presented in the first year with developmental delay are reported. The first boy is normocephalic with spastic diplegia and normal I.Q. Tests in the second year of life showed punctate calcification of the basal ganglia and subcortical white matter and CSF pleocytosis. At 9 years clinical and imaging features are unchanged and CSF including IFN alpha is normal. The second boy at 21 months has dystonic cerebral palsy, slight fall-off in head growth and cognitive delay. Imaging abnormalities are more severe than those in the brother, CSF examination reveals pleocytosis and marked increase in IFN alpha. Detailed metabolic and viral studies were negative in both cases. Although the clinical course is not progressive, it is suggested that the brothers have AGS and represent the mild end of the spectrum of the disorder. CSF examination (including IFN alpha), should be performed early in children with an apparently static encephalopathy and brain calcification, as typical abnormalities decrease or disappear with age.

Granulocyte-macrophage colony stimulating factor and interleukin-6 enhanced white blood cell synthesis of leukotrienes in chronic myelogenous leukemia

The effect of Granulocyte-Macrophage, Colony Stimulating Factor (GM-CSF) and Interleukin-6 (IL-6) on leukotriene production by CML white blood cells induced by calcium ionophore (A23187) was investigated and the leukotrienes formed were identified and quantified using high performance liquid chromatography (HPLC). The in vivo levels of IL-6 and LTB4 were determined by enzyme immunoassay reagents, while GM-CSF was measured by enzyme amplified sensitivity immunoassay. Although GM-CSF or IL-6 alone did not stimulate the synthesis of 5-lipoxygenase product, preincubation of the white blood cells of CML with GM-CSF or IL-6 for 30 minutes at 37 degrees C enhanced the ionophore A23187 induced leukotrienes synthesis, thus the CML white blood cell suspension primed with GM-CSF or IL-6 produced 26.6 +/- 2.8 and 18.9 +/- 1.3 pmol LTC4/10(6) cells respectively, and 30.2 +/- 3.6 and 25.5 +/- 2.5 Pmol LTB4/10(6) cells. In contrast minute amount of leukotrienes were produced by the control cells. In vivo levels of GM-CSF, IL-6 and LTB4 were investigated in CML and normal healthy donors, elevated chemotactic B4 was found in plasma from CML (267 +/- 70.4) while the mean value in normal healthy donors was (127 +/- 13.6) pg/ml. The plasma level of GM-CSF was 32.4 +/- 15.7 pg/ml and 10.5 +/- 3.1 pg/ml respectively in CML and normal healthy donors, while the mean value of GM-CSF and IL-6 in normal healthy donors were 6.7 +/- 2.2 and 4.9 +/- 2.4 pg/ml respectively. No significant correlation was observed between the level of LTB4 and the level of GM-CSF or IL-6 in CML.

Endocrine abnormalities in hemodialysis patients with iron overload: reversal with iron depletion

The endocrine function was studied in 9 hemodialysis patients with iron overload (IO) before and after iron depletion. Diagnosis of IO was established by high serum ferritin (> 1100 micrograms/L), high hepatic CT density (> 70 Hounsfield units), and excessive iron stores in bone marrow aspirate (grade 6). At the start of the study, 8 patients had gonadal failure, 6 of whom had hypothalamopituitary disease, and 4 manifested thyroid abnormalities. At the end of the study, the hypothalamopituitary function and thyroid abnormalities improved in all patients except one who manifested hypothalamic disease. Primary gonadal failure persisted in the 8 patients. ACTH stimulation produced adequate increments in plasma cortisol at the start and end of the study. Pancreatic (beta cell) function was adequate at the end of the study as shown by normal oral glucose tolerance test and free insulin increments during the test. The CT scan and follow-up indicated significant iron mobilization from the liver, pancreas, and the adrenal glands. Hormonal studies were repeated in 4 of the 5 patients who manifested endocrine abnormalities and had received recombinant human erythropoietin (rHuEPO), 3 mo after discontinuation of the drug. Improvement in the endocrine function persisted in those patients. Our results indicated that dialysis patients exposed to iron overload are at risk for development of multiple endocrine defects. Fortunately, aggressive iron depletion can mobilize iron from these organs and reverse some of the defects.

Case report: a case of solitary Peutz-Jegher's hamartoma in the small bowel with angiographic evaluation

A case of a solitary small bowel Peutz-Jegher's hamartoma in which angiography revealed the lesion to be vascular is presented. The findings suggest that not all Peutz-Jegher's hamartomas are hypovascular as previously reported and that this type of polyp may mimic other vascular lesions such as haemangiomas and leiomyomas.

Direct oral questions to blood donors: the impact on screening for human immunodeficiency virus

BACKGROUND

In December 1990, the Food and Drug Administration recommended that all United States blood centers implement a policy of asking prospective donors direct oral questions (DOQs) about human immunodeficiency virus (HIV) risk behaviors to increase the safety of the blood supply.

STUDY DESIGN AND METHODS

To evaluate the impact of the DOQ policy, HIV-related deferral and HIV seroprevalence data were analyzed at four American Red Cross blood centers for the year before the policy change and the year after. An epidemiologic analysis with stratification was conducted, including the calculation of odds ratios (OR) and 95-percent CIs.

RESULTS

Two of the four blood centers showed an overall significant increase in HIV-related deferral after implementation of the DOQ policy: OR = 4.04, (95% CI = 3.41, 4.76); OR = 2.93, (95% CI = 2.67, 3.21). The increase in HIV-related deferral was higher for women. HIV seroprevalence decreased at all four centers, including the two that did not see an increase in HIV-related deferrals. Seroprevalence declined by 14 percent in the two centers with increases in HIV-related deferral, which was neither significant nor attributable to DOQs.

CONCLUSION

Given that HIV antibody screening cannot detect HIV-seronegative (but infectious) "window-period" donations, the deferral of at-risk donors may offer some additional protection to the blood supply. However, evidence was not found of an increase in safety of the blood supply as measured by HIV seroprevalence.

Human immunodeficiency virus infection among health care workers who donate blood

OBJECTIVE

To estimate the prevalence of human immunodeficiency virus (HIV) infection among health care workers who donate blood.

DESIGN

Point prevalence survey of blood donors.

SETTING

20 U.S. blood centers that participate in an ongoing interview study of HIV-seropositive blood donors.

MEASUREMENTS

Prevalence rates for HIV in persons who reported being health care workers were measured directly for 6 of the 20 blood centers. For the other 14 centers, we derived the numerator from the interview study in the same manner used for the 6 centers; we estimated the denominator using blood collection logs at those centers and extrapolations from the survey completed at the 6 blood centers.

RESULTS

Between March 1990 and August 1991, 8519 health care workers donated blood at 6 hospitals and other medical facilities. Three persons were HIV seropositive: Two reported being health care workers and having nonoccupational risk factors for HIV infection; the occupation and other possible risk factors of the third seropositive donor could not be determined. Therefore, the highest overall prevalence of HIV infection among health care worker donors at these 6 centers was 0.04% (3 of 8519; upper limit of 95% CI, 0.1%). We estimated that during the same period, approximately 36,329 health care workers were tested for HIV at all 20 centers. Twenty-seven persons infected with HIV who donated at hospitals were identified; 7 did not return for interviews, so their health care occupations could not be verified. Thus, the highest estimated overall prevalence of HIV infection among health care worker donors at the 20 centers was 0.07% (27 of 36,329; upper limit of CI, 0.1%). Of the 20 known health care worker donors, 11 reported nonoccupational risks for HIV infection; 3 of the remaining 9 health care workers described occupational blood exposures that could have resulted in transmission of HIV.

CONCLUSIONS

Blood donors can serve as a sentinel cohort when evaluating the risk for occupationally acquired HIV infection. These findings suggest that among the many health care worker donors in this study, HIV infection attributable to occupational exposure was uncommon.

Erythropoietin treatment in haemodialysis patients with iron overload

Erythropoietic response to exogenously administered recombinant human erythropoietin (rHuEpo) was examined in 11 maintenance haemodialysis patients with iron overload (IO). All had required numerous blood transfusions earlier (> 12 units/year). Diagnosis of IO was established by high serum ferritin (SF) levels (> 1,100 micrograms/l), high hepatic CT density (> 70 Hounsfield units; HU) and excessive iron stores in bone marrow aspirate (grade 6). None of the patients had osteitis fibrosa cystica, aluminium intoxication, haemoglobinopathy or haemochromatosis alleles (HLA A3, B7 and B14). All patients responded to rHuEpo treatment (target haemoglobin level of 9-10 g/dl). None of the patients required iron supplementation or developed 'functional anaemia'. During 30 +/- 3 months of therapy, the initial maintenance dose of rHuEpo (103 +/- 12 units/kg/week) and median SF levels (2,250 micrograms/l) fell (50 +/- 8 units/kg/week and 1,060 micrograms/l, respectively) (p = 0.0003 and 0.0007). The initial and final rHuEpo doses correlated well with the respective SF levels (r = 0.89, p < 0.001). The maintenance dose of rHuEpo required for patients with IO at the start of the treatment period was significantly higher than that (50 +/- 5 units/kg/week) required by a control group of patients with adequate iron stores (SF = 100-600 micrograms/l) who were matched for age, sex and frequency of previous blood transfusions (p = 0.002). The findings suggested that excessive IO caused relative resistance to erythropoiesis on exogenous administration of rHuEpo and that iron supplementation was not warranted during rHuEpo therapy in those patients.

Histopathological study of the bilharzial affection on the bladder and ureter

This study was carried out on 68 cases (50 bilharzial stricture lower ureter, eight vesico-ureteral reflux cases and ten control). In cases of reflux associated with bilharziasis heavy ova-deposition was obvious all through the ureteral wall especially per-ureteral sheath. Also heavy deposition in the bladder wall involved the detrusor and trigonal muscle with fibrosis and obliteration of Waldeyer's space and atrophy and fasciculation of detrusor and trigonal muscle. This implies ureteral rigidity, impaired mobility and compression against a firm detrusor buttress.

Calcification of the large bowel in schistosomiasis demonstrated by computed tomography

Four cases are described in which large bowel calcification was demonstrated on CT. All four patients had mixed infection by Schistosoma haematobium and mansoni, the latter being responsible for this abnormality. Intestinal calcification by S. mansoni is unusual, but is especially well demonstrated by computed tomography.

An evaluation of the use of electrophoresis and carbon furnace atomic absorption spectrometry to determine the copper level in separated serum protein fractions

The results of an evaluation of the use of atomic absorption spectrometry with carbon furnace atomisation to analyse the copper content of individual protein fractions separated by electrophoresis is reported. Albumin copper levels in patients with rheumatoid arthritis were found to be about 1 to 2% of the total serum copper. Both albumin and alpha 2 levels are affected by contamination from residual copper present on the strip. An investigation of this contamination indicated very low blank copper levels in the areas of the strip containing alpha 1 and beta proteins. These results, and the results of analysis of copper in the ultrafiltrate from the same serum samples, are combined to define the copper distribution in a group of patients with rheumatoid arthritis. The determinations that can most readily be carried out by this technique are discussed.

A comparison of tissue gold levels in guinea-pigs after treatment with myocrisin injected intramuscularly and triethylphosphine gold chloride and myocrisin administered orally

A comparative study of tissue gold levels produced in guinea-pigs after the oral administration of either triethylphosphine gold chloride or Myocrisin (sodium aurothiomalate) or after the injection of Myocrisin intramuscularly is reported. Gold concentrations were determined 5, 24 and 168 hours after administration in stomach, small intestine, large intestine, kidney, liver and spleen and 5 and 24 hours after administration in skin, adrenals, heart, lung and brain. In gastrointestinal tissues, tissue gold concentrations were highest with triethylphosphine gold chloride. The stomach gold level 5 hours after oral administration of triethylphosphine gold chloride is particularly high and, taken in conjunction with the other gastrointestinal gold levels measured, suggests that a stomach rather than an intestinal absorption mechanism may predominate. A more extensive time-course study on kidney and liver is reported and the possible relationship between tissue concentration and toxicity is discussed.

Comparison of gold levels and distribution in guinea pig serum

Serum levels after oral administration of 30 mg/kg of sodium aurothiomalate (Myocrisin), triethylphosphine gold chloride, or triphenylphosphine gold chloride to guinea pigs indicated that all were orally absorbed. However, the serum gold level of triethylphosphine gold chloride was three to four times that of Myocrisin or triphenylphosphine gold chloride and was comparable with the serum level produced when the same dose of Myocrisin was injected intramuscularly. A comparative time-course study between intramuscular administration of Myocrisin and oral administration of triethylphosphine gold chl;ride indicated that during the first 24 hours after intramuscular injection of Myocrisin, a large fraction of the gold was not protein-bound, whereas all detectable gold in serum after oral administration of triethylphosphine gold chloride was protein-bound. Gold levels in the separated protein fractions indicate that the gamma-globulin level after oral administration of triethylphosphine gold chloride is approximately three times higher after 24 hours than with intramuscular Myocrisin.