Clinical results of piezoelectric gallstone lithotripsy

The safety and efficacy of piezoelectric extracorporeal shockwave lithotripsy in the treatment of symptomatic gallbladder stones were evaluated in 53 consecutively treated patients. All treatments were performed as outpatients without anesthesia; over 95 per cent of 109 treatments were performed without analgesia or sedation. Ursodeoxycholic acid was administered post-treatment. Seventy per cent of patients had multiple sessions. Cumulative stone-free rates of 38 per cent at 6 months, 65 per cent at 12 months, and 75 per cent at 15 months were achieved. There was no difference in eventual stone clearance between patients with single stones less than 20 mm diameter, single stones greater than or equal to 20 mm diameter, or multiple (two or three) stones, although patients with single smaller stones required significantly fewer total shocks to become stone-free (P = .02). Stone clearance correlated with estimated stone volume. Biliary pain occurred in 62 per cent of patients after treatment but ceased in stone-free patients. Biliary complications of pancreatitis (7.5%) and choledocholithiasis (3.8%) were successfully treated by endoscopic papillotomy. Nonbiliary complications were virtually nonexistent. Three patients (5.7%) had elective cholecystectomy. Results indicate that piezoelectric lithotripsy is a safe, minimally painful treatment that, in conjunction with oral bile acids, can produce stone-free rates of 75 to 100 per cent in selected patients.

Case report 696: Chondroblastoma of the right acetabulum and superior pubic ramus

A case of chondroblastoma involving the right acetabulum and superior pubic ramus in a 60-year-old man has been presented. Tissue was obtained by open biopsy. The clinical and radiographic characteristics of chondroblastoma in general, and this tumor in particular, were discussed. The histopathology and differential diagnosis were also considered. The relatively uncommon site of the tumor and its occurrence in an older patient made the radiographic diagnosis difficult, and other possibilities were discussed.

DNA methylation changes in the IL-1 (2F) chromosomal region of some radiation-induced acute myeloid leukaemias carrying chromosome 2 rearrangements

Acute myeloid leukaemias (AML) arising in irradiated CBA/H mice frequently have breakpoints in the F region of chromosome 2. The closely linked cytokine genes interleukin (IL)-1 alpha and beta map to this region, and the beta gene is deregulated in some AMLs. Using pulsed-field gel electrophoresis techniques, we show here that an 800 kb 2F region encoding IL-1 alpha and beta is not obviously rearranged in six leukaemias carrying chromosome 2 abnormalities. However, changes in IL-1 region DNA methylation in three leukaemias may be consistent with loss of hypermethylated sequences from one chromosome copy. These possible 2F region losses are discussed in relation to genomic imprinting and its potential role in murine myeloid leukaemogenesis.

Renal insufficiency and secondary hyperparathyroidism in elderly patients

Glomerular filtration rate (GFR) is frequently reduced in elderly people. However, the effect of this on mineral metabolism in this population has received little attention. GFR, serum intact parathyroid hormone (PTH) and vitamin D metabolites were measured in 37 patients admitted to hospital for various reasons. In 20 patients with GFR greater than 50 mL/min, an elevated serum intact PTH concentration (greater than 5.4 pmol/L) was found in two, while in 17 patients with GFR less than 50 mL/min PTH was elevated in 13. One of this group was hypercalcaemic and presumed to have primary hyperparathyrodism. Adjusted calcium was normal in all other patients. Two patients had a low serum 25-hydroxyvitamin D concentration (less than 9 nmol/L) suggesting vitamin D insufficiency while a further five had a reduced 1,25-dihydroxyvitamin D concentration, four of these having a GFR less than 50 mL/min. We conclude that hyperparathyrodism is common in hospitalized elderly patients, particularly in those with mild to moderate renal insufficiency. This may contribute to bone mineral loss in such patients.

Development of faculty consultants in a problem-based third year community medicine clerkship

This paper describes the development of consultancy groups in behavioral science, epidemiology and biostatistics, and information science in a required community medicine rotation with a twenty year history. The addition of consultants to individual student tutors and field preceptors has led to a structure which promotes student-project flexibility, development of critical assessment skills and independent learning while maximizing faculty expertise and effectiveness.

Eruptive vellus hair cysts and neurologic abnormalities: two related conditions?

A fifteen-year-old white boy with a history of seizure disorder, borderline cognitive function, academic difficulty, and explosive temper outbursts was evaluated for asymptomatic flesh-colored papules appearing on his chest, abdomen, and axillae. Examination of a biopsy specimen showed eruptive vellus hair cysts; results of genetic, endocrinologic, and neuropsychiatric evaluation revealed abnormalities suggestive of a previously undescribed neurocutaneous syndrome.

Graduate training in community medicine at Mount Sinai: the development of the Master of Science in Community Medicine

This paper describes the philosophy, process, and outcome of the integration of independent study and classroom training with existing clinical and research experiences in The Mount Sinai Medical Center Department of Community Medicine's general preventive medicine and occupational medicine residencies leading to the creation of the Master of Science in Community Medicine.

Interleukin-1 beta gene deregulation associated with chromosomal rearrangement: a candidate initiating event for murine radiation-myeloid leukemogenesis?

The incidence of acute myeloid leukemia (AML) in CBA/H mice following exposure to single acute doses of ionizing radiation has previously been determined. A high proportion of these AMLs are characterized by rearrangement of murine chromosome 2 in the C2 and/or E5-F regions, and there is evidence that these events are a direct consequence of radiation damage to multipotential hemopoietic cells. Using a combination of in situ chromosome hybridization and mRNA analyses, we show that the cytokine gene interleukin-1 beta (IL-1 beta) is encoded in the chromosome 2 F region and is translocated in a chromosome 2---2 rearrangement in an x-ray-induced AML (N36). Also, IL-1 beta is specifically deregulated in N36 and in two other chromosome 2-rearranged AMLs but not in a fourth, which has two cytogenetically normal chromosome 2 copies. We suggest that radiation-induced specific chromosome 2 rearrangement associated with IL-1 beta deregulation may initiate murine leukemogenesis through the uncoupling of normal proliferative control mechanisms in multipotential hemopoietic cells.

Time accounting in community medicine education

This paper describes the approach used by the Department of Community Medicine of the Mount Sinai School of Medicine in the formulation of personnel time requirements for undergraduate medical education. The results presented reveal that the two required undergraduate courses utilize a total of 5627 hours of faculty and support staff time. Implications of this method are discussed for program budgeting in medical education and the use of various course methods (e.g., lecture, seminar, tutorial).

Urinary excretion of albumin and retinol-binding protein during normal pregnancy

In a cross sectional study of 88 pregnant women urinary excretion of albumin, when expressed as a ratio to creatinine concentration, was not significantly different from that in a non-pregnant control group of similar age (p greater than 0.05) and did not change significantly during pregnancy. Only when albumin excretion was expressed as a fractional clearance was the urinary excretion significantly increased in the third trimester compared with the first trimester (p less than 0.05), although it was still not significantly different from that in the non-pregnant control group. Excretion of retinol-binding protein was significantly increased during all three trimesters of pregnancy (p less than 0.01 in each case) and more so in the second and third trimesters than in the first. It is concluded that the increased total protein excretion that has been described during pregnancy is not explained by an increased excretion of albumin which remains essentially normal. In contrast, the tubular absorption of proteins is decreased.

Immunoassays for low concentrations of albumin in urine

We have developed and validated simple, rapid immunoassays to measure concentrations of albumin in urine ranging from 5 to 200 mg/L. We use antiserum to human albumin, raised in sheep, and we separate the antibody-bound and free fractions of albumin by using a second antiserum, produced in donkeys, against the Fc fragment of sheep IgG. These two antisera can be mixed and added to assay tubes as a single reagent without inhibiting antigen binding. Samples or standards are incubated for at least 30 min with fluorescein-labeled albumin and the premixed antiserum reagent. After brief centrifugation, the supernate is discarded and the precipitate containing the bound fraction is dissolved and its fluorescence measured. Alternatively, 125I-labeled albumin can be used as tracer with all other reagents unchanged; in this case one simply counts the radioactivity of the bound fraction. A reference interval of less than 0.2-2.8 mg/mmol of creatinine was obtained for untimed, daytime, midstream urine specimens from 80 healthy subjects.

Immunoassays for low concentrations of albumin in urine

We have developed and validated simple, rapid immunoassays to measure concentrations of albumin in urine ranging from 5 to 200 mg/L. We use antiserum to human albumin, raised in sheep, and we separate the antibody-bound and free fractions of albumin by using a second antiserum, produced in donkeys, against the Fc fragment of sheep IgG. These two antisera can be mixed and added to assay tubes as a single reagent without inhibiting antigen binding. Samples or standards are incubated for at least 30 min with fluorescein-labeled albumin and the premixed antiserum reagent. After brief centrifugation, the supernate is discarded and the precipitate containing the bound fraction is dissolved and its fluorescence measured. Alternatively, 125I-labeled albumin can be used as tracer with all other reagents unchanged; in this case one simply counts the radioactivity of the bound fraction. A reference interval of less than 0.2-2.8 mg/mmol of creatinine was obtained for untimed, daytime, midstream urine specimens from 80 healthy subjects.

Community-oriented health services education: a strategy for international cooperation

This paper describes the approach of the Department of Community Medicine of the Mount Sinai School of Medicine in the education of local and foreign physicians and their participation in the development of community oriented health care systems. It also presents the first steps taken by this medical school to create an international program whose aims are to develop long-term partnership agreements with foreign universities by bringing together and integrating medical education with the development of community-oriented health care services.

Familial corneal scarring: a new dystrophy?

A 34-year-old white man with skin manifestations of the epidermal nevus syndrome was found to have anesthetic corneas, dry eyes, and localized opaque nodular elevations of both corneas. Similar corneal lesions, unassociated with corneal anesthesia, were found in four family members. Histology of corneal biopsies from the proband revealed superficial stromal scarring. The possible relationship between this familial condition and Salzmann's nodular corneal dystrophy, Goldenhar syndrome, and epidermal nevus syndrome is discussed.

Effects of pregnancy on the febrile responses in sheep

Pyrogens were injected into unshorn pregnant and non-pregnant Soay and Clun Forest sheep and the effects on rectal temperature and thermoregulatory mechanisms monitored. Plasma concentrations of unconjugated oestrogens, progesterone and cortisol were measured in the sheep tested in late pregnancy. The effect of pyrogens was also examined in ovariectomized ewes treated with oestrogen and with oestrogen plus progesterone. In contrast to reports of work on shorn sheep all sheep developed a fever even when close to term but the increase in peripheral vasomotor tone normally induced by pyrogens was attenuated in the pregnant Clun Forest ewes. The hormone-treated ovariectomized animals developed normal fevers and provided little indication of a possible relation between peripheral levels of ovarian steroids and the degree of fever. The question of whether an endogenous antipyretic substance is present in pregnant sheep is discussed.

The possible involvement of aspartate receptors in central thermoregulation in the sheep

Experiments have been done to investigate the possible existence of aspartate receptors on the hypothalamic pathways which control thermoregulation in the sheep. The effect of intracerebroventricular (I.C.V.) injections of the excitatory amino acid receptor blocker DL-alpha, epsilon-aminopimelic acid (DAPA) on thermoregulatory effector mechanisms and rectal temperature (Tre) has been examined in sheep at different ambient temperatures. At low ambient temperatures, DAPA causes a decrease in heat production and conservation and a fall in Tre. At higher ambient temperatures there is some evidence for a decrease in heat loss and a rise in Tre. DAPA attenuated the stimulatory effect on heat-production/conservation mechanisms produced by I.C.V. injections of L-aspartate but was without effect on the thermoregulatory responses to I.C.V. injections of carbachol and 5-hydroxytryptamine or I.V. injections of a pyrogen. I.C.V. injections of the L-aspartate analogue, N-methyl-DL-aspartate produced similar effects to L-aspartate. The results provide support for the suggestion that aspartate receptors may be present on the hypothalamic pathway between cold-sensors and heat-production/conservation effectors. Evidence for the existence of such receptors on the pathway between warm-sensors and heat-loss effectors remains scant.

Choline acetyltransferase and acetylcholinesterase containing projections from the basal forebrain to the amygdaloid complex of the rat

The origin of the cholinergic innervation to the amygdaloid complex was investigated with the use of acetylcholinesterase (AChE) histochemistry and choline acetyltransferase (ChAT) assay of microdissected nuclei. Visualization of AChE-positive neurones in the ventral forebrain was facilitated by pretreatment of rats with 1.5 mg/kg di-isopropyl phosphofluoridate (DFP). The AChE-positive neurones in the ventral forebrain are distributed in a continuous system from the septum through the lateral preoptic area to the entopeduncular nucleus caudally. Knife cuts or kainic acid injections (1.5 microgram/l microliter) placed in the lateral preoptic area resulted in substantial depletion of the AChE and ChAT content of the amygdala nuclei. Kainic acid injections (1.5 microgram/l microliter) in the diagonal band area or cuts through the stria terminalis dorsally did not significantly modify the AChE staining or ChAT content of the amygdala (although diagonal band injections partially depleted the hippocampus of ChAT). Knife cuts severing both the so-called ventral pathway and the stria terminalis did not produce significantly greater ChAT depletion in the amygdala than those produced by the knife cuts or kainic acid injections in the lateral preoptic area. Parasagittal knife cuts undercutting the lateral pyriform cortex also failed to modify the AChE or ChAT content of the amygdala, but they depleted the undercut cortex of both ChAT and AChE; AChE-positive material accumulated ventrally and medially to the knife cut. It is suggested that the major source of the cholinergic innervation of the amygdala is the magnocellular AChE-positive neurones in the lateral preoptic area and adjacent regions of the ventral forebrain.