[Emergency catheterization in a coronary intensive care unit. The diagnostic and therapeutic implications]

OBJECTIVE

to evaluate the diagnostic and therapeutic role of emergency hemodynamic studies, in the coronary intensive care (UCI).

STUDY DESIGN

Retrospective study of--patients (P) submitted to emergency catheterization.

PATIENTS

183 P (152 M and 31 F), mean age 56 +/- 11.5 years, admitted to UCI of Hospital Santa Marta and who had cardiac catheterization performed, between October 88 and November 92.

METHODS

Patient clinical files were reviewed. We considered the reasons for emergency cardiac catheterization; final diagnosis; complications in the first 24 hours; catheterization role in the therapeutic orientation.

RESULTS

Reasons for hemodynamic study were: coronary artery disease (CAD) in 127 P (69%); aortic dissection in 33 P (18%); valvular disease in 19 P (10%) and other in 4 P (3%). Clinical diagnosis was confirmed in 92% and changed in 8% by hemodynamic study results. Left main coronary artery disease was diagnosed in 6.5% of CAD patients. Coronary artery disease was excluded in 5 P with previous CAD diagnosis, in 19 P with aortic dissection and in 11 valvular patients. 32% of P were sent to emergent surgery: 93% ascending aortic dissection and 20% of CAD, 76% of valvular disease. The hemodynamic study was decisive in the therapeutic option of myocardial revascularization in 77% of P with CAD: 39 emergent PTCA (31%), 13 primary (33%) and 14 P oriented to elective PTCA (11%); 26 emergent surgery and 19 P oriented to elective surgery (15%). The emergency cardiac catheterization mortality rate was 0.5%, and the morbidity 2.7%.

CONCLUSIONS

The contribution of Hemodynamic Department to UCI was decisive in the diagnostic and therapeutic orientation of critical patients.

[Tuberculous meningitis: prognostic aspects of 22 microbiologically confirmed cases]

BACKGROUND

Tuberculous meningitis continues to be a severe disease difficult to diagnose within a reasonable time carrying a high morbimortality.

METHODS

A retrospective review of cases of microbiologically confirmed tuberculous meningitis diagnosed and treated in the authors' institution is presented.

RESULTS

From 1974-1993, 22 patients (12 males and 10 females, mean age of 31.5 years; range: 4 months and 77 years) were studied. Eighteen patients (81%) presented extrameningeal tuberculosis. Seven (31.8%) died and 6 (27.3%) presented severe neurologic sequelae. The worst prognosis was observed in patients older than the mean (p = 0.03), worse neurologic situation on admittance (p = 0.03) and hydrocephaly diagnosed by imaging techniques (p = 0.04). Corticoids were administered in 15 patients (68%) without contributing comparatively to better disease prognosis.

CONCLUSIONS

The authors consider that the initiation of specific early treatment in justified while awaiting microbiologic confirmation of the disease.

Clinical significance of primary vs. secondary bacteremia due to nontyphoid Salmonella in patients without AIDS

We retrospectively reviewed the charts of 51 patients with primary nontyphoid salmonella (NTS) bacteremia who did not have AIDS and who had no history of gastroenteritis and no other identified source of infection. We compared these patients with 58 patients who developed secondary NTS bacteremia following an episode of gastroenteritis. The following characteristics were more frequently associated with primary NTS bacteremia than with secondary NTS bacteremia: age > 60 years (51% vs. 33%; P < .05), glucocorticoid therapy (41% vs. 13%; P < .01), and severe immunosuppression (65% vs. 14%; P < .01). More patients with primary NTS bacteremia had hematologic malignancies, solid tumors, and connective-tissue diseases; in eight cases, primary NTS bacteremia occurred simultaneously with or preceded these disorders. We suggest that the possibility of severe immunosuppression be investigated for patients with salmonella bacteremia who have not had or do not have gastroenteritis.

[The clinical spectrum of focal infection due to nontyphoid Salmonella: 32 years' experience]

BACKGROUND

The aim of this study was to analyze the manifestations of the syndromes which constitute focal infection by Salmonella no typhi (SNT).

METHODS

Ninety-one episodes of SNT infections studied over a period of 32 years in the Fundación Jiménez Díaz (Madrid, Spain) were retrospectively analyzed.

RESULTS

Of the 1,892 patients with SNT infection studied during this period, 91 (5%) presented some focal form (57 males and 34 females) with a mean age of 49 years (SD +/- 21.6 years). Sixty percent of the episodes were acquired within the community. The localization of the focal infections by SNT was as follows: urologic tract (24%), intraabdominal (20%), soft tissues (16%), respiratory tract (15%), osteoarticular (14%), cardiovascular (10%) and central nervous system (1%). On comparison with the remaining patients, those with urinary, osteoarticular and respiratory infections were found to be the most frequently immunosuppressed (47%) vs 18%, p < 0.01) with a greater frequency of unfavorable evolution (57% vs 15%; p < 0.001). Mortality ranged between 7% for the osteoarticular forms to 64% for the pleuropulmonary forms of infection.

CONCLUSIONS

Focal infection by Salmonella no typhi may be localized in any organ usually occurring in immunosuppressed patients or those with predisposing local factors. The osteoarticular, pulmonary, and urologic infections have a particularly unfavorable course and their presence may suggest the existence of immunosuppression.

Laparoscopy and colon cancer. Is the port site at risk? A preliminary report

PURPOSE

To quantify the magnitude of the risk for port/extraction site recurrence of laparoscopically resected colon cancer in a defined study population.

METHODS

The data from a prospective laparoscopic bowel surgery registry was used to identify cases of colon cancer that were resected laparoscopically, with a minimum follow-up of 1 year. A questionnaire was sent to the surgeons who performed the procedures.

RESULTS

A total of 252 cases were identified from the registry. Questionnaires were returned in 208 of those cases, a response rate of 82.5%. Three cases of port or extraction site recurrence were noted, two of them associated with diffuse peritoneal carcinomatosis. All the patients had a Dukes' stage C tumor at the time of initial surgery.

CONCLUSIONS

The incidence of port/extraction site recurrence following laparoscopic colon cancer surgery is low. All the recurrences were in patients with Dukes' stage C tumors, and there was diffuse peritoneal carcinomatosis in two of the three cases, suggesting that port/extraction site recurrence may be attributable to the advanced nature of the disease rather than the laparoscopic technique. Longer follow-up and more cases are required to confirm these findings.

[Coronary fistula --clinical and angiographic review]

OBJECTIVE

To evaluate clinical and angiography date of patients (pts) in whom coronary arteriovenous fistula were detected.

STUDY DESIGN

Retrospective study of diagnostic coronary angiographies done between 1988 and 1993 in whom coronary arteriovenous fistula were detected.

SETTING

Patients submitted to cardiac catheterisation in the Cardiology Department of Santa Marta Hospital in whom coronary arteriovenous were detected.

PATIENTS

Fourteen pts, 10 male and 4 female, with a mean age of 49 years (21-72).

INTERVENTIONS

A retrospective analysis of clinical data and coronary artery anomalies was done. Whenever available, the Pulmonary Artery and the shunt (calculated through oximetries) were evaluated.

RESULTS

The following pathologies were associated: rheumatic valve heart disease (3 pts), Tetralogy of Fallot (2 pts), atrial septal defect--ostium primum (1 pt), dilated cardiomyopathy (1 pt), hypertrophic cardiomyopathy (1 pt), atherosclerotic coronary artery disease (2 pts). Four pts were in atrial fibrillation and the others in sinus rhythm. Four pts had normal ECG. In 6 pts there was cardiomegaly on the chest X-rays. The fistula was single in 11 pts, double in one and multiple in 2 other pts. The fistula originated from the right coronary artery in 6 pts, the left anterior descending coronary artery in 5 pts, the circumflex coronary artery in 3 pts and the left main coronary artery in one pt. Eight drained to the pulmonary artery (or its branches), 2 to the coronary sinus, one directly to the right atrium, one to the right ventricle and one to the left atrium. In only 2 pts the fistula was closed. In 6 pts the associated anomalies were corrected. With a mean follow up of 24 months (1-72), 8 pts are asymptomatic, 4 complain of slight heart failure, 3 of angina pectoris and the pt with dilated cardiomyopathy died 1 year after being studied.

CONCLUSION

A male predominance was found. Most fistulae were single. The artery mostly involved was the right coronary artery and the fistula drained more often to the pulmonary artery or its branches.

Debrisoquin oxidation genotype and susceptibility to lung cancer

The association between the polymorphism of the cytochrome P450 debrisoquin hydroxylase (CYP2D6) and lung cancer is controversial. Previous reports suggested a link between CYP2D6 phenotype and lung cancer, with poor metabolizers having reduced susceptibility. Nevertheless, negative findings have also been published. By using allele-specific amplification, we have studied the frequency of four CYP2D6 (wild type and mutant) alleles in 89 patients with histologically proved bronchogenic carcinoma and in 98 healthy volunteers. Our findings confirm that poor metabolizers are underpresented among patients with lung cancer because of a different genetic background. Our findings also reveal that the rare CYP2D6(C) mutant allele is sixfold more frequent among patients with lung cancer (p < 0.0005). This suggests that the CYP2D6(C) allele could be considered as an additional risk factor because carriers could have higher susceptibility to the development of lung cancer.

[Bacteremia caused by anaerobes: analysis of 131 episodes]

BACKGROUND

Despite the efficacy of modern antimicrobials bacteremia by anaerobes (AB) continues to present a high mortality rate. The aim of this study was to determine the relative frequency and clinical significance of isolations of anaerobic bacteria in blood cultures and to know the prognostic factors of AB.

METHODS

From total of 231 patients observed over a period of six and a half years in the Fundación Jiménez Díaz, 131 episodes of AB were retrospectively analyzed with special attention being given to microbiologic, epidemiologic and clinical factors.

RESULTS

The relative frequency of AB was 7.5%. Clinical significance was found in 86 out of the 131 episodes (66%). The isolation of Bacteroides spp. was clinically significant in 89% while Clostridium spp. was so only in 33% (p < 0.001). Mortality related with AB was 32%. The following factors were considered related to bad prognosis statistical analysis (p < 0.05): admission to medical areas, rapid and finally fatal underlying disease, presence of septic shock, renal failure, inappropriate antimicrobial treatment and the absence of drainage for the septic foci.

CONCLUSIONS

Anaerobic bacteremia remains an important cause of bacteremia and carries a high mortality rate. Two thirds of the episodes of anaerobic bacteremia are deemed to be clinically significant. Correct antimicrobian treatment and surgical drainage of any septic foci significantly improves prognosis.

Isolation of Nocardia sp. from blood cultures in a teaching hospital

To determine the clinical significance of the isolation of Nocardia sp. from blood cultures, clinical records of patients with bacteremia due to Nocardia sp. in our hospital from January 1986 to December 1990 were retrospectively reviewed. Eight patients had 9 blood cultures positive for Nocardia sp. Four of the isolates were identified as Nocardia asteroides. Only 2 of the patients had disseminated nocardiosis due to N. asteroides, and both were appropriately treated for Nocardia sp. In the other cases, isolation of Nocardia sp. was considered nonsignificant or undetermined, and all were clinically cured. Nocardia sp. may be an occasional contaminant of blood cultures. The significance of nocardemia is a matter of clinical judgment.

[The complications associated with the performance of heart catheterizations (diagnostic and therapeutic). The results in the Hemodynamics Laboratory of Hospital de Santa Marta]

OBJECTIVES

To evaluate the morbidity and mortality with cardiac catheterization (diagnostic and intervention).

DESIGN

Retrospective analysis of complications occurring within 24 h of a cardiac catheterization, in three consecutive years (1989-1991).

SETTING

Patients admitted to the Haemodynamic Laboratory of Santa Marta Hospital-Lisbon.

PATIENTS

4014 patients submitted to diagnostic and interventional procedures.

MATERIALS AND METHODS

Registry analyze in order to obtain the following data: pathology, age, vascular approach and complications of cardiac catheterization.

RESULTS

In three years there were 4014 cardiac procedures. 53.6% were performed in patients with coronary artery disease, 20% with valvular heart disease, 8.1% with congenital heart disease, 16.1% with others pathologies and 2.2% revealed normal vessels in coronary angiography. The incidence of ischemic heart disease was progressively higher in the studied years: 51.9% in 1989, 52.4% in 1990 and 55.2% in 1991. Data from population age showed the same tendency: mean age was 51, 53 and 55 years, respectively. Femoral approach was attempted in 95% of the studies, and the axillary in 2.15%. Complications of diagnostic and interventional cardiac procedures occurred in 3% of the patients. Dead occurred in 0.14%; arrhythmia, 0.37%; vascular, 0.14%; vasovagal/pyrogen reactions, 0.73%; myocardial infarction, 0.05%; and others, 1.58%.

CONCLUSION

The diagnostic and interventional cardiac catheterization in experienced laboratories are a safe procedure with a reduced incidence of major complications.

Integration of statistical and physiological analyses of adaptation of near-isogenic barley lines

Seven near-isogenic barley lines, differing for three independent mutant genes, were grown in 15 environments in Spain. Genotype x environment interaction (G x E) for grain yield was examined with the Additive Main Effects and Multiplicative interaction (AMMI) model. The results of this statistical analysis of multilocation yield-data were compared with a morpho-physiological characterization of the lines at two sites (Molina-Cano et al. 1990). The first two principal component axes from the AMMI analysis were strongly associated with the morpho-physiological characters. The independent but parallel discrimination among genotypes reflects genetic differences and highlights the power of the AMMI analysis as a tool to investigate G x E. Characters which appear to be positively associated with yield in the germplasm under study could be identified for some environments.

Infection caused by the nonfermentative gram-negative bacillus CDC group IV c-2: case report and literature review

A 10-year-old girl with acute lymphocytic leukemia developed nosocomial septicemia caused by the gram-negative bacterium CDC group IV c-2. Recovery of the patient followed appropriate treatment with ceftriaxone, to which the organism was susceptible in vitro. Four other reported cases of infection caused by this organism are reviewed.

[The recurrence of an atrial myxoma in a patient with a mechanical mitral prosthesis--apropos a case]

Recurrence of cardiac myxoma after surgery is an uncommon situation, particularly if a wide excision of the tissue under the tumour has been done. The authors report a case of a 54-year-old male presenting with a left atrial myxoma near the mitral valve, which had to be replaced by a mechanical prosthetic valve during the removal of the tumour. One year later, he was admitted to hospital with persistent fever, weight loss, and congestive heart failure. After a positive hemoculture, intravenous antibiotherapy was initiated, and twice modified because of relapsing fever. Six weeks later, he was transferred to our institution, after an episode of severe acute pulmonary edema. 2D-Doppler echocardiography suggested the possibility of prosthesis dysfunction, revealing a transprothetic diastolic flow with a high peak velocity and moderately elevated pressure half-time. No intra-atrial masses were visualized. Computed tomography was also inconclusive, because of multiple artifacts produced by the prosthesis. These results led to the performance of a cardiac catheterization with contrast ventriculography, which revealed the presence of a transprothetic gradient, and mild mitral regurgitation. The patient was submitted to cardiac surgery, which revealed a recurrent pedunculated left atrial myxoma, with mechanical obstruction of the mitral prosthetic valve. No signs of endocarditis were found. Recurrent cardiac myxomas are reviewed and discussed, as well as the specific problems of the present case, namely the presence of a mechanical prosthetic mitral valve and the initial hemoculture results, with consequent diagnostic delay.

[Capnocytophaga spp. bacteremia in compromised patients]

BACKGROUND

To analyze the clinical characteristics of three patients with Capnocytophaga spp. bacteremia.

METHODS

We have review the clinical charts of three patients with Capnocytophaga spp. bacteremia, two patients with acute leukemia and one epileptic patient with chronic alcoholism.

RESULTS

All the patients had oral cavity troubles and were treated with different antimicrobial agents. The three patients recovered, one of them requiring changing of the antimicrobial therapy in one of them.

CONCLUSIONS

We should be aware of the importance of Capnocytophaga spp. especially in immunosuppressed patients or in other patients with poor dental hygiene and fever.

[Primary pulmonary hypertension. Clinico-pathologic analysis]

We present a case of primary pulmonary hypertension, confirmed by open lung biopsy. The interest of the case resides in the microscopic study of the specimen, and the patient's prognosis is discussed. The physiopathology of the disease is reviewed and the palliative therapeutic measures that can be adopted.

[Pulmonary artery involvement in Takayasu arteritis. A case of right ventricular failure as presentation form]

Pulmonary involvement in Takayasu's artery disease has been reported since 1940 with an incidence of 14 to 56%. However, the development of severe pulmonary hypertension is an extremely rare event in the natural course of the disease. The authors report a case of a 62 year old male presenting with severe congestive heart failure of recent onset. The initial evaluation and routine exams suggested the presence of pulmonary hypertension of unknown etiology. The absence of left radial pulse in the physical examination led to the performance of a complete angiographic study which confirmed the diagnosis of Takayasu's arteritis with pulmonary involvement and severe pulmonary hypertension.

[Pre-sternal invasion as first manifestation of lung epidermoid carcinoma]

Lung epidermoid carcinoma is a tumor of central origin and slow growth which tends to invade locally; however, it is rare to find a presternal tumoration produced by local invasion as one of its manifestations. The aim of this communication is to present a case and analyze its natural history.

[Value of two-dimensional echocardiography in the prognosis of patients after acute myocardial infarction]

OBJECTIVES

To evaluate the prognostic importance of two-dimensional echocardiography in patients (pts) with acute myocardial infarction.

SETTING

Department of Cardiology in a Central Hospital.

METHODS

In 71 pts (63 men and 8 women) aged 35 to 75 years interned with a proved myocardial infarction, a score of left ventricular segmental wall motion was used on echocardiographic examination performed during the late hospital phase, to evaluate left ventricular function. Two groups of pts were considered: group A constituted by 38 pts with complication detected during follow-up that ranged 4 to 18 months; group B by 33 pts with no cardiac events for the same period. The relation of the wall motion score with each group and the location of myocardial infarction was performed.

RESULTS

In group A, the mean score index was 1.67 in pts with angina, 1.08 in pts with heart failure and 0.82 in pts who died. The mean score index was 1.25, 1.57 and 1.18 respectively in pts with an anterior, inferior and antero-inferior infarction. In group B, the mean score index was 1.70 in pts with an anterior infarction, 1.85 in those with an inferior infarction and 1.33 in the patient with an antero-inferior infarction. Patients with a non-Q wave infarction had a mean score index of 2. The mean score index was significantly different between group A and B (respectively 1.33 vs 1.79; p less than 0.00001) and a mean score index of 1.53 was considered the mean risk value.

CONCLUSIONS

Two-dimensional echocardiography performed during hospital predischarge permits risk stratification after acute myocardial infarction, specially for death and heart failure.

Quantitative phenotypical expression of three mutant genes in barley and the basis for defining an ideotype for Mediterranean environments

Three mutants induced in the two-rowed barley variety Beka and their three binary recombinants have been used in an attempt to define an ideotype suitable for Mediterranean agroclimatic conditions. Physiological methods (classical plant growth analysis) together with the study of genotype x environment interaction for grain yield were used to characterize the genotypes. That characterization brought out the huge phenotypical variation produced by only three mutant genes, suggesting that single Mendelian genes may alone explain the quantitative variation, including grain yield, without the necessity of using the polygenic concept. The genotype best adapted to the environments studied is later in heading and has shorter straw and denser spikes than Beka; it also has higher inverse of leaf area rate and grain: leaf area ratio, a lower rate of leaf senescence, and a shorter grain filling period than the original variety.

[Exercise 2D-Doppler echocardiography, for the evaluation of aortic valve prostheses]

STUDY OBJECTIVE

Exercise evaluation of eccentric monocuspid aortic prosthetic valves.

DESIGN

Prospective study, using 2D Doppler echocardiography to analyse resting and exercise aortic flow patterns.

SETTING

Laboratory of Echocardiography at Santa Marta Hospital.

PATIENTS

Sequential sample of 28 patients with aortic prosthesis (19 Bjork-Shiley and 9 Hall-Kaster), without evidence of either cardiac failure, coronary artery disease, prosthesis dysfunction or stress test contraindication.

INTERVENTIONS

Transaortic basal and exercise flow record, using Doppler echocardiography to analyse: instantaneous peak velocity (pv) and gradient (pg), systolic time intervals, heart rate (hr) and stress test time (stt). The patients were divided in two groups A (prosthesis valve size 19 and 21) and B (greater than 21).

RESULTS

Technical success: 84%. basal pv ranged from 1.6 to 4.5 m/s in group A and 1.7 to 3 m/s in B. Rest pg was 35 +/- 1% mmHg--Group A--and 20 +/- 8 mmHg in B (p less than 0.01), increasing with stress test respectively to 62 +/- 26 (p less than 0.01) and 36 +/- 12 mmHg (p less than 0.001). 73% of group A patients had exercise pg greater than 50 mmHg. The correlation between basal and exercise pg was significant (r = 0.91 p less than 0.001). At rest the systolic time intervals revealed a significant difference between the two groups (p less than 0.05), while only the ejection time was significant with stress test (p less than 0.01). Exercise hr and stt were greater in group B-p = NS.

CONCLUSIONS

These exercise Doppler echocardiography data suggest that mechanical moncuspid aortic prosthesis 19, 21 and same 23, result in left ventricular outflow obstruction mainly during exercise; these facts should be taken into account when aortic prosthesis insertion is considered. Given the good correlation between resting and exercise peak gradient, Doppler stress test is not routinely recommended in clinical practice.

[Non-invasive evaluation of systolic pressure of the pulmonary artery in patients with tricuspid regurgitation, using Doppler echocardiography]

STUDY OBJECTIVE

To quantify the systolic pulmonary artery pressure (SPAP) by continuous wave Doppler echocardiography and record the prevalence of tricuspid regurgitation (TR).

DESIGN

Prospective analysis of 42 patients (pts), submitted to right heart catheterization (RHC).

SETTING

Pts referred to the Echocardiographic Laboratory at Sta. Marta Hospital - H.C.L.

PATIENTS

Sequential sample of 42 pts with several cardiac pathologies, subjected to RHC and 2D Doppler Echocardiography.

INTERVENTIONS

The right ventricular and SPAP were recorded in the hemodynamic exam. We considered pulmonary hypertension (PH) if SPAP was greater than 35 mmHg or mean pressure greater than 20 mmHg. The pts were divided into two groups: I-pts without PH and II-pts with PH. The 2D Doppler echocardiography was made within 24 H of the hemodynamic one. Peak gradient (pg) of TR and the correlation with catheterization data were analysed.

RESULTS

Hemodynamic--The mean SPAP in the sample was 46 +/- 21.5 mmHg (27 +/- 4.6 in group I and 55 +/- 20.2 mmHg in II). In 35 pts with TR the mean SPAP was 50.3 +/- 21.2 mmHg. Doppler--The pressure gradient was 40 +/- 18.7 mmHg. 57% pts of the group I and 96% II had TR p less than 0.001. The correlation between Doppler gradient and SPAP was r = 0.95, and no change was noted when 7 is used as a constant.

CONCLUSION

Continuous wave Doppler echocardiography is a non invasive technic useful to the quantitative analysis of SPAP.

Effects of atropine injection on food-associated drinking in rats with superior salivatory nucleus lesions

The neuropharmacological mechanisms involved in the prandial drinking pattern seen in rats with superior salivatory nucleus lesions + parotidectomy were investigated with behavioral methods. Results showed that the administration of low doses (0.1 mg/kg body wt) of atropine in lesioned rats potentiated previously established prandial drinking. Higher doses of atropine (1.0 mg/kg), however, were required to induce a similar degree of prandiality in control rats (parotidectomy alone). These findings suggest that the salivatory nucleus lesions affected a cholinergic brainstem-salivary gland system involved in the neural control of food-associated drinking.

[Flow patterns of a normally functioning monocuspid aortic prosthesis evaluated using Doppler echocardiography]

STUDY OBJECTIVE

Flow analysis in normally functioning eccentric monocuspid aortic prosthetic valves, to obtain a reference data list.

DESIGN

To analyse, using 2D-Doppler Echocardiography, aortic flow velocity and systolic time intervals in clinically normal patients (pts), by physical examination.

SETTING

Referred pts to the Echocardiographic Laboratory at Santa Marta Hospital--HCL.

PATIENTS

Sequential sample of 61 pts with aortic prosthesis (41 Bjork-Shiley and 20 Hall-Kaster) without clinical evidence of either cardiac failure or significant aortic regurgitation. Patients with bad quality record were also excluded.

INTERVENTIONS

Doppler Echocardiography was used to record transaortic flow, and the following indexes were analysed: instantaneous peak velocity (pv) and gradient (pg), presence of regurgitation, systolic time intervals and both preejection period/ejection time (PEP/ET) and acceleration time/ejection time (AT/ET).

RESULTS

Pv ranged from 1.1 to 4 m/sec (mean 2.4 +/- 0.2. The prosthesis size 19 and 21 showed a greater pg compared to the larger ones: 46.3 +/- 14.4 mmHg against 12.6 +/- 6.4 mmHg (p less than 0.001). Occasionally a pg over 50 mmHg was found in the prosthesis size 19 and 21. The correlation between prosthesis size and pg was also significant (r = -0.62; p less than 0.001). PEP interval was 60 +/- 10 milisec in prosthesis no. 19 and 90 +/- 13 milisec in no. 27 (p less than 0.01). AT ranged from 77 +/- 14 to 88 +/- 14 milisec (mean 82 +/- 13). ET was 294 +/- 5.4 milisec in valves size 19 and 257 +/- 34 millisec in no. 25 (p less than 0.05); there was also a significant difference between prosthesis size 19 and 27 (p less than 0.05). Mild regurgitation was detected in 32.7% of cases.

CONCLUSIONS

These data may be particularly useful as reference values to the follow-up of pts these types of prosthesis. Significant differences were found in pg between different valve sizes and this should be remembered when proceeding to standard evaluation by 2D-Doppler Echocardiography. Regurgitation is frequently detected in normally functioning prosthesis, not deeper than 2 cm in the left ventricle.

Peripheral pathways mediating salivary secretion after nucleus parvocellularis activation in the rat

The present study demonstrates that activation of the nucleus parvocellularis in the pontine reticular formation of the rat evokes salivary hypersecretion. The secretory effect observed was found to be mediated by parasympathetic mechanisms, as transection of the preganglionic parasympathetic salivatory fibers at the level of the middle ear blocked the flow of saliva evoked by activation of the nucleus parvocellularis (Experiment 1). Furthermore, transection of these salivatory fibers was followed several days later by the development of a prandial model of drinking. These behavioral data suggest that the transection procedure employed in the present study indeed affected those parasympathetic fibers which control the secretory activity of all three pairs of major salivary glands (Experiment 2).

Salivatory neurons in the brainstem nucleus parvocellularis of the rat: effects of electrolytic lesions

This study was based on several recent anatomical studies suggesting that the superior salivatory nucleus is located within the area parvocellularis of the brainstem reticular formation. The aforementioned zone was lesioned in order to observe the alterations produced in salivary secretion. Electrolytic lesion of the area parvocellularis was followed by salivary hypersecretion as an immediate and transitory effect of the stimulatory capacity of the electrolytic lesioning method. Some days later the animals presented a markedly impaired salivary secretion as shown by the appearance of inefficient feeding behavior and the development of a prandial drinking pattern. The prandial behavior, which was characterized by numerous drinking episodes during dry food intake, was reversed when wet food was offered, suggesting a true deficit in salivary secretion caused by the parvocellularis lesion. Following the administration of pilocarpine, the submandibular and sublingual salivary glands of experimental animals showed an increased capacity for response (postsynaptic supersensitivity) in comparison to the control group.

Resolution of methamphetamine stereoisomers in urine drug testing: urinary excretion of R(-)-methamphetamine following use of nasal inhalers

The objective of this study is to determine whether R(-)-methamphetamine inhaled from nasal inhalers produces positive methamphetamine results in currently used urine drug screening procedures and to present a rapid method for distinguishing the optical isomers of methamphetamine. Urine from three subjects inhaling from a Vicks Nasal Inhaler every 20 min for six hours tested positive for methamphetamine by EMIT, Toxilab, TDx, and GC/MS. The chiral derivatizing reagent N-trifluoroacetyl-L-prolyl chloride (L-TPC) was used to form methamphetamine diastereomers allowing rapid identification of each stereoisomer of methamphetamine present in the urine samples. Urine samples positive for amphetamines during routine drug screening were determined to consist of a racemic mixture of methamphetamine. The isomeric composition of methamphetamine present in a urine sample indicates the probable source of the drug.

The nucleus parvocellularis reticularis regulates submandibular-sublingual salivary secretion in the rat: a pharmacological study

This experiment shows that activation of the nucleus parvocellularis reticularis in the rat brainstem provokes salivary hypersecretion by the submandibular-sublingual glands. The secretory effect is mediated by cholinergic mechanisms, as the administration of atropine blocked the flow of saliva evoked by stimulation of the nucleus parvocellularis. In contrast, injection of dihydroergotamine (an alpha-blocker) and/or propranolol (a beta-blocker) failed to significantly reduce submandibular and sublingual salivary secretion when compared to a control group injected with distilled water. The cholinergic nature of the salivary response suggests that the nucleus parvocellularis reticularis exerts its secretory effect on the salivary glands parasympathetically rather than through mechanisms associated with sympathetic pathways. The area of the brainstem activated in the present study closely overlaps the region in which cell bodies of superior salivatory neurons have recently been identified with retrograde transport of peroxidase. The data presented herein represent functional proof in support of the location of the superior salivatory nucleus within the parvocellularis reticular formation.

Legionnaires' disease in a Johannesburg teaching hospital. Investigation and control of an outbreak

During the period 11 November 1985 - 21 February 1986, 12 cases of Legionnaires' disease were identified at a Johannesburg teaching hospital. Only 2 patients definitely acquired the disease in hospital. Both responded well to treatment. An epidemiological investigation was initiated to determine the source of infection and mode of transmission of the causative agent (Legionella pneumophila), which may be recovered from a wide variety of water sources. Although L. pneumophila was cultured from the hospital hot-water system, there was no association between the location of patients and culture-positive water sites. Cases were clustered in the medical and surgical intensive care units. Being on a ventilator was a significant risk factor for acquiring Legionnaires' disease (relative risk 18,4; 95% confidence interval 2,4 - 142,2). The potential role of ventilators in the transmission of the disease is discussed together with the infection control measures adopted to interrupt the outbreak. To our knowledge this is the first investigation of an outbreak of Legionnaires' disease in South Africa.

Submandibular and parotid salivary secretion after electrolytic lesioning of the brainstem nucleus parvocellularis in the rat

The present study, in consonance with recent anatomical investigations, demonstrates that activation of the nucleus parvocellularis in the rat evokes a potent hypersecretory effect in the submandibular and sublingual (S-S) salivary glands. Furthermore, electrolytic lesioning of this region in conjunction with peripheral removal of the parotid glands is followed by an increase in the number of drinking responses in the presence of dry food. Such prandial drinking behavior is only observed after total impairment of salivation (i.e., removal of the S-S + parotid glands), thus suggesting that the parvocellularis lesion led to a marked deficit in S-S salivary secretion. On the other hand, the activation of the nucleus parvocellularis was seen to have only a slight effect on parotid salivary secretion. Electrolytic lesions to this zone, when associated with peripheral removal of the S-S glands, failed to induce prandiality, suggesting that the parvocellularis nucleus exerted a low level of control over parotid salivary secretion. These results are interpreted as functional proof of the relationship between the parvocellularis reticular formation and the superior salivatory nucleus in the secretion of S-S saliva.

Urographic findings in adults with chronic pyelonephritis

The radiological findings in a cohort of 138 adults with chronic pyelonephritis are presented and the following conclusions made. Scarring is commoner in the right kidney than the left and is found in the upper, middle and lower poles with decreasing frequency from above down. Agreement between observers in the grading of scarring in urograms taken without standardisation or routine tomography, is sufficiently high to justify the continued use of the intravenous urogram as a screening test but is not high enough to detect any progression of scars in the group over a 6.5-year period. Repetition of urograms seldom reveals the development of calculi or other new abnormalities and is not justified as a clinical routine. The combination of extensive bilateral renal scarring and proteinuria is associated with the worst renal function.

Surgical aspects of continuous ambulatory peritoneal dialysis--3 years experience

Since January 1979, 122 patients (mean age 38.5 years, range 5-72 years) with chronic renal failure have been treated with continuous ambulatory peritoneal dialysis (CAPD). Peritoneal access was achieved by inserting silicone rubber Tenckhoff peritoneal dialysis catheters (Quinton, Seattle, Washington) by an open (76 per cent) or closed technique. Actuarial analysis showed a patient survival of 98 and 94 per cent and a success rate of 88 and 64 per cent at 1 and 2 years, respectively. Currently, 74 patients are using CAPD and 8 have been treated for 30-36 months. Thirty-five patients (29 per cent) required two or more peritoneal catheters and 69 per cent of these patients are still on CAPD. Catheter-related peritonitis was the most frequent complication (233 separate episodes in 94 patients) and necessitated catheter removal in 16 per cent of episodes, although 37 per cent of patients from whom catheters were removed because of peritonitis later resumed CAPD. Extravasation of dialysate from the peritoneal cavity (31 episodes) and catheter obstruction (31 episodes) required surgical replacement of catheters in 8 and 23 cases, respectively. Twenty patients (16 per cent) developed 24 abdominal hernias, only one of which caused failure of CAPD. Infective and mechanical complications of CAPD frequently require surgical intervention but only occasionally result in failure of the technique, and even multiple catheter replacements are compatible with successful long term CAPD.

Sequential changes in serum lipids and their subfractions in patients receiving continuous ambulatory peritoneal dialysis

Serum cholesterol, triglycerides and their fractions in high density (HDL), low density (LDL) and very low density (VLDL) lipoproteins were measured sequentially in fasting patients on continuous ambulatory peritoneal dialysis (CAPD) who entered a prospective study. Of the 30 who entered, all have been followed to 3 months, 24 to 6 months and decreasing numbers to 18 months. Serum total cholesterol, VLDL cholesterol, total triglycerides and VLDL triglycerides all rose significantly during the first 6 months and VLDL cholesterol has remained elevated to 18 months. Changes in other fractions have been insignificant or inconsistent. 1 patient has developed angina. No associations were found between use of high dextrose fluid, weight gain and hyperlipidemia, probably because of consistent practice between patients. Our results confirm the adverse effect of CAPD on serum lipids and the need for dietary modification but are broadly similar to the changes that have been observed during regular hemodialysis.

Continuous ambulatory peritoneal dialysis: three years' experience

We review the experience of the Renal Unit at Newcastle upon Tyne over the three years 1979-1981, during which 122 patients with chronic renal failure were treated by continuous ambulatory peritoneal dialysis (CAPD). Advantages of the technique included wide acceptability to a cross-section of patients reaching the renal unit, including the elderly and diabetics. Patients who experienced both techniques preferred CAPD to haemodialysis because of the greater freedom and sense of well-being. Patient survival was 94 per cent at two years and rehabilitation was as good as could be expected for the age and primary medical complications of the patients. Control of plasma potassium and phosphate was easier than with haemodialysis. Renal osteodystrophy responded well to a combination of CAPD and alfacalcidol therapy over the two year period for which we have performed serial bone biopsies. Serum aluminium was slightly raised as a result of consumption of phosphate binders and presumed uptake from dialysis fluid but no aluminium related disease has yet been encountered. Anaemia was partly corrected by CAPD with haemoglobin rising to about 10 g/dl on average. CAPD was less costly than home haemodialysis over the first three years and has been adopted as our standard treatment for patients who can expect an early transplant. Disadvantages were persisting problems with peritonitis which still occurred at an incidence of one attack per 39 patient weeks over the last two years, and an actuarial success rate for the technique of only 63 per cent at two years. Twenty patients developed hernias. Weight gain was common and occasionally gross. There was a significant rise in serum cholesterol. The arrival of CAPD has allowed us to increase the intake to our renal failure programme by 50 per cent. However, continued expansion of the technique demands advances in prevention of peritonitis, adequate facilities for admission and particularly an expanding hospital haemodialysis programme to accept the less successful patients from CAPD.

Peritonitis in continuous ambulatory peritoneal dialysis. Laboratory and clinical studies

During a three year period, 1979-81, 82 patients were treated by continuous ambulatory peritoneal dialysis (CAPD). The incidence of peritonitis was reduced significantly during the three years from one episode per 20 patient-weeks to one episode every 37 patient-weeks. 83% of the 136 episodes of peritonitis were treated successfully by antibiotic therapy alone. 62% of the total episodes were managed successfully with intraperitoneal cefuroxime. in 13 (16%) patients, CAPD failed because of peritonitis. Hospital admission for peritonitis has been reduced to a mean of 4.3 days per patient per year of CAPD. Fron January to September, 1982, Clostridium-difficile colitis developed in 13 patients. This complication was associated with considerable mortality and morbidity and has prompted a change in antibiotic policy. Patients with peritonitis are now given intraperitoneal netilmicin and intravenous vancomycin. Peritonitis remains the main complication of CAPD, but can be minimised by development of adequate facilities for performing CAPD.

Purification and chemical characterization of a W2 protein from brain myelin

Starting from a pellet of beef brain myelin insoluble in chloroform/methanol (2:1, vol/vol)(Wolfgram protein fraction), a pure W2 protein with apparent molecular weight of 52,000 was isolated by a simple preparative sodium dodecyl sulfate-polyacrylamide gel electrophoresis method. A comparative chemical analysis was carried out between purified W2 and a standard tubulin. Glutamic acid and arginine were the N-terminals detected. Similar peptide maps and amino acid composition were also found in both proteins. Immunological cross-reactivity was detected when W2 protein was tested against antitubulin serum. These results suggest that W2 protein could have a tubulin-like protein nature that is associated with the myelin membrane and could play a role in the myelination process.