Primary systemic amyloidosis

We report here a case of a 35-year-old male who presented with multi-system disease, which on evaluation was found to be due to primary systemic amyloidosis. We present the myriad manifestations of this uncommon disease entity.

Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration

BACKGROUND

Leakage of fluid occurs along the longitudinal folds within the wall of an inflated high-volume, low-pressure cuff. Theoretically, lubrication of the cuff with a water-soluble gel might prevent aspiration by plugging the channels in the cuff wall. Pulmonary aspiration during anesthesia has been linked with postoperative pneumonia and during critical illness causes ventilator-associated pneumonia.

METHODS

Lubricated cuffs were compared with nonlubricated cuffs for leakage of dye placed in the subglottic space to the tracheobronchial tree in a benchtop model (n = 5) and in a prospective double-blinded randomized controlled trial of anesthetized patients (n = 36). The duration of the efficacy of the lubricant was determined in a prospective open observational study of critically ill patients with tracheostomies (n = 9). Dye was detected clinically by dye coloration of secretions during tracheal suctioning.

RESULTS

In the benchtop model the incidence of leakage was 0% in the lubrication group and 100% in the nonlubrication group (P < 0.01). Dye leakage in anesthetized patients was 11% in the lubrication group and 83% in the nonlubrication group (P < 0.0001). In the critically ill patients with lubricated cuffed tracheostomy tubes, leakage first occurred after a median period of 48 h (range, 24-120 h).

CONCLUSIONS

Cuff lubrication with a water-soluble gel reduces pulmonary aspiration in anesthetized patients. In the critically ill patient with a tracheostomy the protective effect is lost after 24-120 h.

Single incision for implanting a vagal nerve stimulator system (VNSS): technical note

BACKGROUND

A technique for implanting the vagal nerve stimulator system through a single incision is described.

METHOD

A transverse incision is made in the lower part of the neck. Subcutaneous (s.c.) dissection is then done over the clavicle into the infraclavicular area to create a pocket. The vagus nerve is exposed and the electrodes are wrapped around it through the neck incision. The distal ends of the lead are connected to the pulse generator, and latter is then placed in the infraclavicular pocket through the neck incision.

RESULTS

Thirty-eight implants were conducted with this technique. The pulse generator could be implanted and anchored to the underlying tissue without any difficulty. Except for wound infections in two patients there was no other complication.

CONCLUSION

A single incision is an alternate to the double incision procedure. This procedure can be performed safely.

Concordant prune belly syndrome in monozygotic twins

We report 2 cases of concordant prune belly syndrome occurring in monozygotic twins. In addition to suggesting a genetic basis for this disease, our 12-year follow-up of these cases illustrates that these patients with an otherwise poor prognosis can have normal growth, development, and renal function with appropriate treatment.

Human immunodeficiency virus encephalitis in SCID mice

The human immunodeficiency virus (HIV) is neuroinvasive and commonly causes cognitive and motor deficits during the later stages of viral infection. (referred to as HIV dementia). The mechanism(s) for disease revolves around secretory products produced from immune-activated brain macrophages/microglia. Recently, we developed an animal model system for HIV dementia that contains xenografts of HIV-1-infected cells inoculated into brains of mice with severe combined immunodeficiency (SCID). This animal system was used to quantitatively evaluate HIV-induced neuropathology. Xenografts of HIV-1-infected human monocytes (placed into the putamen and cortex of SCID mice) remained viable for 5 weeks. HIV-1 p24 antigen expression in mouse brain was persistent. Progressive inflammatory responses (including astrogliosis and cytokine production), which began at 3 days, peaked at day 12. The range of astrocyte proliferative reactions exceeded the inoculation site by > 1000 microns. Brains with virus-infected monocytes showed a > or = 1.6-fold increase in glial fibrillary acidic protein (staining distribution and intensity) as compared with similarly inoculated brains with uninfected control monocytes. These findings paralleled the accumulation and activation of murine microglia (increased branching of cell processes, formation of microglial nodules, interleukin (IL)-1 beta and IL-6 expression). An inflammatory reaction of human monocytes (as defined by HLA-DR, IL-1 beta, IL-6, and tumor necrosis factor-alpha expression) and neuronal injury (apoptosis) also developed after virus-infected monocyte xenograft placement into mouse brain tissue. These data, taken together, demonstrate that this SCID mouse model of HIV-1 neuropathogenesis can reproduce key aspects of disease (virus-infected macrophages, astrocytosis, microglial activation, and neuronal damage). This model may serve as an important means for therapeutic development directed toward improving mental function in HIV-infected subjects with cognitive and motor dysfunction.

Vertebrobasilar thrombosis associated with nonpenetrating cervical spine trauma

Vertebral artery injuries associated with blunt trauma to the cervical spine are rare. Five cases of vertebrobasilar complications after blunt trauma to the cervical spine are reported. Four were involved in motor vehicle accidents, and one suffered a diving injury. All of these patients had documented cervical spine fractures. For two patients, the diagnosis of vertebral artery thrombosis was made on the basis of magnetic resonance angiography (MRA), and for the remaining three, cervical four-vessel arteriograms (CFVAs), were used. All the patients had occlusion of flow in either the vertebral artery or in the vertebrobasilar circulation. The patients presented with acute, non-specific changes in neurological status. Two patients had infarctions in the vertebrobasilar tertiary, one had an infarction in the middle cerebral artery territory, and two did not show evidence of cerebral infarction. Three of the patients were treated with anticoagulants. Of these, two showed a stabilization of their neurological status, and one died. The four surviving patients improved with early physical and occupational therapy. Although CFVA remains the "gold standard" for diagnosing these injuries, newer modalities, such as MRA, may be useful adjuncts. Early stabilization of the cervical spine injury and anticoagulation are beneficial.

Spectrum of illness in rural areas of Ahmednagar District

At Pravara Medical Trust (PMT), Loni, Ahmednagar, multidiagnostic and treatment camps (MDTC) are organised by PMT every month in remote villages with active participation of villagers, to provide health care to needy and deprived population. From January 1987 to April 1992, 58 camps have been organised and 60,856 patients availed various medical and health services rendered by PMT. Average attendance of patients per camp was 1049, 48.36% being females and 51.64% males. According to the International Classification of Diseases (ICD) patients were broadly grouped. A total of 21,603 (35.5%) were referred to the Pravara Rural Hospital and 15,700 (72.67%) of them availed the indoor and outdoor services there.

LA, Johnson ZB. Feed intake and digestion by Holstein steer calves consuming low-quality grass supplemented with lasalocid or monensin

Holstein steer calves were fed late vegetative bermudagrass or mature bromegrass free choice in three Latin-square experiments to determine influences of ionophore type and level, supplementation with cereal grain, and source of low-quality grass on feed intake and digestion. In exp. 1, neither lasalocid nor monensin given at 0.5 mg kg−1 of body weight (BW) affected intake or digestion with either forage source. In exp. 2, steers received lasalocid or monensin at 0, 0.5 or 1.0 mg kg−1 of BW. Neutral detergent fiber digestibility was not depressed by ionophores and was slightly greater (P < 0.05) for ionophores at 1.0 than at 0.5 mg kg−1 of BW. Digestible organic matter intake with bermudagrass was slightly greater with ionophores at 1.0 than at 0.5 mg kg−1 of BW, but an opposite difference between ionophore levels occurred with bromegrass (ionophore level × forage source interaction; P < 0.07). The concentration of total volatile fatty acids in rumen fluid at 4 h post-feeding was lower (P < 0.05) for monensin than for lasalocid; the acetate/propionate ratio was decreased by ionophores and was lower for monensin than for lasalocid (P < 0.05). In exp. 3, lasalocid at 0.5 mg kg−1 of BW did not affect intake or digestion or interact with supplemental corn (7.2 g kg−1 of BW) or forage source. In conclusion, level of ionophore maximizing digestible organic matter intake may vary with characteristics of source of low-quality forage. However, when present, effects of ionophores on digestibility or energy intake may be relatively small. Key words: Cattle, ionophore, forage, intake, digestion

Effects of various supplements on voluntary intake and performance by growing cattle consuming forage moderate to high in crude protein

Growing cattle were supplemented with substances to lessen or increase ruminal ammonia level to determine if consumption of moderate- to high-crude protein (CP) forage is limited by high ruminal ammonia absorption. In Experiment 1 (5 x 5 Latin square), five Holstein steers (198 kg) had ad libitum access to alfalfa cubes (17% CP) without supplementation or with corn at 0.25 or 0.75% body weight (BW) alone (LC or HC) or with 0.06% BW of zeolite (chabazite; LC-Z and HC-Z). Total daily organic water (OM) intake was not affected by treatment (6.08, 6.14, 6.11, 6.19 and 6.09 kg for control, LC, LC-Z, HC and HC-Z, respectively; SE 0.25). In Experiment 2, Simmental crossbred beef calves grazed fescue-clover paddocks in the spring (clipped forage: 21 to 27% CP) for 84 days and were supplemented with 0.25 or 0.75% BW corn alone or with added zeolite (0.06% BW) or lasalocid (0.5 mg/kg BW). Daily gain did not differ among treatments (1.24 to 1.31 kg/day). In Experiment 3 (6 x 6 Latin square), six Holstein steer calves (168 kg) had ad libitum access to medium-quality, orchardgrass-clover hay (15% CP). Steers received one of the following six treatments: no supplement (Control), 0.35% BW ground corn (C), corn plus 0.049% BW urea (C-U), 0.35% BW soybean meal (S), 0.205% BW feather meal (F) or 0.103% BW feather meal, 0.052% BW blood meal and 0.067% BW corn gluten meal (F-BG). Total daily OM intake was 5.00, 5.14, 5.00, 5.11, 4.84 and 4.70 kg for control, C, C-U, S, F and F-BG, respectively (SE 0.13). In Experiment 4 (6 x 6 Latin square), six Holstein steer calves (226 kg) were fed 0.75% BW of alfalfa cubes (19% CP) plus ad libitum access to medium- to high-quality orchardgrass hay (16% CP). Steers received one of the following six treatments: no supplement (Control), corn at 0.25% BW alone (c) or mixed with 0.12% BW peanut skins (C-PSK), a mix of high-CP feedstuffs high in ruminal escape protein (0.029% BW blood meal, 0.038% BW corn gluten meal and 0.028% BW feather meal; C-REP), 0.139% soybean meal (C-S) or soybean meal plus peanut skins (C-PSK-S). Total daily OM intake was 6.16, 6.25, 6.13, 6.52, 6.50 and 6.60 kg for control, C, C-PSK, C-REP, C-S and C-PSK-S, respectively (SE 0.10).(ABSTRACT TRUNCATED AT 400 WORDS)

DL, Forster Jr. LA, Li F, West CP, Johnson ZB, Patil A, Sun W. Liveweight gain by beef calves grazing cool-season annual grass in the spring and supplemented with grass hays

Supplementing beef calves grazing cool-season annual grass with warm- or cool-season grass hay (0.4% liveweight), differing in cell wall content, depressed weight gain more by heifers than steers. Adding supplemental corn (0.8% liveweight) to hay only improved gain by heifers, though gain was not greater than controls for either gender. Key words: Cattle, beef, supplements, pasture, corn, hay

The value of intraoperative scans during CT-guided stereotactic procedures

The accuracy stereotactic procedures performed during the pre-computed tomography (CT) era was confirmed by intraoperative X-ray pictures. With the availability of CT it is now possible to confirm the position of the probe-tip on an image of the target. For biopsy of small lesions in critical areas of the brain, permanent placement of radioactive seeds, or thalamotomy, it would be desirable to have confirmation of the site of the probe-tip prior to performing the main step of the procedure. Intraoperative CT was performed in 216 stereotactic procedures carried out on the scanner table including biopsies, aspiration of cysts, brachytherapy, aspiration of abscesses, thalamotomy, and evacuation of intracerebral hematoma. In 6 cases, inaccuracies were detected, which it was possible to correct so as to place the probe where desired.

Stereotactic microsurgical resection of intracranial tumors using the electromagnetic field focusing system

The intense heat produced at the tip of the electromagnetic field focusing (EFF) probe at its point of contact with tissue can cut and vaporize tissue and coagulate blood vessels. As the probe is shaped like a bayonet and has a diameter of 0.3 mm at its tip, it can be used on deep structures through narrow openings, making it ideal for stereotactic craniotomy. Thirteen stereotactic craniotomy procedures using the EFF system were performed. Locations of the lesions were deep in the cerebrum, cerebellum and in the lateral ventricle. The system proved efficient with reduced blood loss and unobstructed view of deep structures. No complications resulted from the use of the system.

Electromagnetic field focusing system in clinical neurosurgery--preliminary report

The electromagnetic field focusing system is capable of sharply focusing induced current resulting in pinpoint heating of tissue. This heat can cut and vaporize tissue while simultaneously coagulating vessels. This is a report on the first 15 consecutive neurosurgical cases where this system was used for tumor excision. The system was found to be an effective and safe surgical tool. It functioned effectively, even under saline and cerebrospinal fluid and through narrow openings during stereotactic microsurgical procedures.

Histological and bacteriological studies of burn wounds treated with boiled potato peel dressings

Histological and clinical studies have been made on comparable burn wounds covered with either boiled potato peels affixed to gauze bandages or gauze dressings alone; both dressings were applied over a thin layer of 5 per cent silver sulphadiazine. Compared with treatment with plain gauze dressings, the application of the potato peel dressing reduced or eliminated dessication, permitted the survival of superficial skin cells and hastened epithelial regeneration. Bacteriological studies showed that the potato peels had no intrinsic antibacterial activity, the wounds beneath both dressings showing either no growth or, on most occasions, the same bacterial species. The easy availability of potato peels and gauze bandages on to which they can be affixed, the simplicity of the preparation of this dressing, the ease of sterilization and its low cost of production make this the dressing of choice for burn wounds in our developing country.

Electromagnetic field focusing (EFF) probe for intravascular endarterectomy. Preliminary feasibility study

Vaporization of atheromas in 10 human aorta segments immersed under flowing blood in vitro were done using the EFF probe. No increase in packed cells of the flowing blood following atheroma vaporization were noted suggesting absence of post vaporization debris. No damage to the aorta underlying the vaporized atheroma was noted on light microscopy suggesting well localized vaporization process. This study suggests that EFF probe might be a safe tool for intravascular endarterectomy.

The study of the effect of human chorionic gonadotrophic (HCG) hormone on the survival of adrenal medulla transplant in brain. Preliminary study

Autologous adrenal cortex was completely dissected off the medulla using microdissection. The adrenal medulla tissue was transplanted to the lateral ventricle in twenty-one adult rats. Group A consisting of ten animals received 200 units of HCG per 100 gram body weight daily for one week and then on every alternate day for seven weeks. The remaining rats (group B) served as control. After eight weeks the brains were removed and a volumetric study was done using histological sections. High pressure liquid chromatography (HPLC) with electrochemical detection for catecholamine assay of the graft was also undertaken. The graft survival in group A was significantly higher (p less than 0.005) than group B. The level of norepinephrine was significantly higher in group A while dopamine was higher in group B. The higher volume of graft tissue in group A suggests that HCG may help in increased survival and growth of the transplanted tissue. Higher levels of norepinephrine in group A would suggest a tendency for such grafts to be active to a greater extent with the treatment of HCG.

Recoiling suture and methylmethacrylate in aneurysm thrombosis. Preliminary report

Injection of acrylic material into the aneurysm is a relatively simple procedure if escape of the material into the circulation can be prevented by means of a coil inserted into the aneurysm prior to injection of the acrylic material. In the present study, polypropylene (00000) suture was given a coiling property. On extrusion through a 22 gauge spinal needle the suture regained its coiled shape. Experiments were carried out on dogs with the external carotid artery serving as a model for an aneurysm. Using a 22 gauge spinal needle, first the coiled suture was inserted into the aneurysm and then methylmethacrylate was injected. Ten aneurysms were thrombosed. None of the animals suffered a neurological deficit. Complete thrombosis of the aneurysms were noted in all the animals. On perfection, this technique could eventually be used for stereotaxic thrombosis of intracranial aneurysms.

Tricuspid regurgitation by radionuclide angiography and contrast right ventriculography: a preliminary observation

In a retrospective study correlating the degree of tricuspid regurgitation seen on first-pass radionuclide angiography with that seen on contrast right ventriculography in 51 patients, ten had no tricuspid regurgitation by contrast ventriculography, whereas by radionuclide angiography nine had no regurgitation and one had minimal regurgitation. Of eight patients with minimal tricuspid regurgitation by contrast ventriculography, five had minimal regurgitation by nuclide angiography and three had no regurgitation. Of the 11 patients with mild to moderate tricuspid regurgitation by contrast studies, ten had mild to moderate regurgitation and one had severe regurgitation by nuclide angiography. Of 22 patients with moderate to severe tricuspid regurgitation by contrast studies, 15 had moderate to severe regurgitation and seven had mild to moderate regurgitation by nuclear angiography. In this preliminary study comparing radionuclide angiography with contrast right ventriculography, there were three false-negative and one false-positive nuclide angiograms, giving a sensitivity of 93% and a specificity of 90%.