Radio-immunoassay for formyl methionyl leucyl phenylalanine. II. Demonstration of an enterohepatic circulation of immunoreactive bacterial chemotactic peptides in man

Bacterial chemotactic peptides (F-met-oligopeptides) are secreted by several species of commensal enteric bacteria and can be assayed by bioassay techniques in human colonic luminal fluid. We have previously demonstrated intestinal absorption and enterohepatic circulation of radiolabelled F-met peptides introduced into rat colon, and an eightfold increase in absorption and biliary excretion in rats with experimental colitis. This paper describes the application of a radio-immunoassay to measurements of formyl oligopeptides in human faecal dialysates, colonic and systemic venous blood and bile. All samples were fractionated by reverse-phase high performance liquid chromatography (HPLC) prior to assay. Immunoreactivity was found in faecal dialysates (5-700 nmol/L F-met-leu-phe equivalents) and bile samples (3-150 nmol/L) from normal subjects. After HPLC fractionation, up to five distinct peaks of immunoreactivity were identified. One of these co-chromatographed with authentic F-met-leu-phe; the others probably represented either closely related peptides or peptides of different chain lengths originating from the same F-met-leu-phe precursor protein. Colonic venous blood from two patients with ulcerative colitis contained immunoreactive peptide (10-30 nmol/L) and substantial immunoreactivity was found in ileostomy fluid and bile from two patients with primary sclerosing cholangitis. These results suggest the presence of an enterohepatic circulation of bacterial F-met oligopeptides in man and provide a basis for studies of the role of such pro-inflammatory peptides in patients with inflammatory bowel disease and associated hepatobiliary disorders.

Fifteen- to twenty-year results after the Hill antireflux operation

Antireflux surgery, specifically the Hill procedure, has been shown to be effective management of refractory reflux when assessed in the relatively short term. This study follows 441 patients from the time of their initial operation and reports on assessments conducted after 5 to 10 years and 15 to 20 years. The late study group comprises 167 patients (mean age 71 years) with an average follow-up of 17.8 years; 15.6% of patients had undergone a previous antireflux operation. Overall subjective good and excellent results, as determined by the patients themselves, were seen to improve significantly (p less than 0.02) between the two follow-up periods, 82% and 88%, respectively. No serious late complications such as fistula, bleeding, or obstruction were observed in this series. The Hill antireflux operation, properly performed, provides durable long-term results.

Early experience with the automatic implantable cardioverter defibrillator in sudden death survivors

Medical management of life-threatening ventricular arrhythmias is difficult because of the toxicity and limited efficacy of antiarrhythmic drugs. The automatic implantable cardioverter defibrillator (AICD) offers protection against malignant ventricular arrhythmias and allows some patients to be managed without antiarrhythmic drugs. We reviewed our experience with the AICD to determine its safety and efficacy. Since June 1987, 24 patients (mean age 63 years) who survived out-of-hospital ventricular fibrillation or hemodynamically unstable ventricular tachycardia not associated with acute myocardial infarction had implantation of an AICD. None had inducible monomorphic ventricular tachycardia associated with ventricular aneurysm. Twenty-three had abnormal left ventricular function (mean ejection fraction 0.32). There were no operative deaths and three complications. At last follow-up (mean 8.9 months) 23 patients were alive. Eight patients had one or more AICD discharges associated with symptomatic or monitored cardiac arrest. AICD implantation can be performed with low risk and appears to be an effective alternative to antiarrhythmic therapy with toxic drugs.

Introducer insertion of mini-thoracostomy tubes

Introducer insertion of a small caliber chest tube is easily mastered, fast, and nearly painless. Outpatient management of spontaneous pneumothorax with a 12 F. polyvinylchloride catheter and a Heimlich valve appears both safe and economical in a selected group of patients. Introducer chest tube insertion is well tolerated, in contrast to the discomfort experienced during insertion of chest tubes by means of blunt dissection or trocar. In addition, the high risk of injury to the lung or other viscera by trocars is avoided.

Improved results of surgical treatment for esophageal and gastroesophageal junction carcinomas after preoperative combined chemotherapy and radiation

Combined treatment with chemotherapy and radiation (chemoradiation) preceding surgical exploration for esophageal or gastroesophageal squamous cell carcinoma or adenocarcinoma was compared with surgical exploration alone to determine if there was an influence on tumor status at exploration, tumor resectability, disease recurrence, and patient survival. Preoperative chemoradiation resulted in significant tumor response as measured by decreased nodal involvement and 36% incidence of no residual tumor at resection (total response) and was reflected by an improvement in resectability. Local tumor recurrence was eliminated by preoperative chemoradiation preceding resection. Distant recurrence was not reduced and remained the major cause of death. The 2-year survival rate after tumor resection alone was 33% versus 66% after preoperative chemoradiation and resection (p = 0.13). Patient survival after resection alone was predicted by pathologic extent of local disease as measured by lymph node status. In contrast, survival after chemoradiation and resection was not predicted by pathologic extent of local disease. Surgical resection appears to have been an important component of therapy, primarily because survival was improved in patients after resection of residual local disease.

Acrocyanosis due to imipramine

An 11 year old girl who was being treated for enuresis with imipramine developed acrocyanosis of the hands and feet. All biochemical and haematological investigations gave normal results. When imipramine was stopped the girl recovered within three days.

Tests of the ribosome editor hypothesis. III. A mutant Escherichia coli with a defective ribosome editor

Peptidyl-tRNA dissociates from the ribosomes of Escherichia coli during protein biosynthesis. The ribosome editor hypothesis states that incorrect peptidyl-tRNAs dissociate preferentially. Editing would therefore prevent the completion of proteins containing misincorporated amino acids. We have isolated a mutant strain of E. coli that dissociates some peptidyl-tRNAs at a fivefold lower rate than its parent strain, and that synthesizes significantly more erroneous complete proteins. This strain is also partially resistant to the antibiotic erythromycin, which in wild-type E. coli stimulates the dissociation of peptidyl-tRNA from ribosomes. The data suggest that in this mutant all peptidyl-tRNAs are bound to the ribosome more tightly than normally during protein synthesis. Because of the inverse correlation between the accuracy of synthesis of complete proteins and the rate of dissociation of peptidyl-tRNA from the ribosome, we propose that the mutant contains a defective ribosomal editor.

Memory evaluation of alcoholics with Russell's revised Wechsler Memory Scale

Fifty-four alcoholics and 30 nonalcoholics were tested on Russell's (1975) revision of the Wechsler Memory Scale (RWMS). Subjects were dichotomized into groups of old and young, and alcoholics were divided further into groups of short- and long-term abusers. Groups were matched on socioeconomic status. Significant group differences were found on three of the four RWMS measures as a function of abuse status and on two of the measures as a function of age. In terms of severity of impairment, alcoholics were found to demonstrate only mild verbal and figural memory deficits when compared to age-matched controls. Results are discussed with regard to the clinical utility of the RWMS as a memory screening instrument with alcoholic patients and in terms of treatment implications.

Cardiovascular perfusion: evolution to allied health profession and status 1986

The occupation of cardiovascular perfusion has evolved from a technical to a professional status during the past 25 years. The national thoracic surgical organizations, The American Association for Thoracic Surgery and the Society of Thoracic Surgeons, have supported this process of development through participation on various boards and committees of the perfusionist organizations. The rapid growth of cardiac surgical services in the past decade produced concern about the availability of perfusionist manpower. This concern was exacerbated by creation of formal processes for the certification of perfusionists and the accreditation of perfusion educational programs. Today, these issues are largely resolved and cardiovascular perfusion is recognized as an allied health profession.

Role of surgery in the treatment of inflammatory breast carcinoma

Twenty-eight patients with inflammatory carcinoma of the breast have been retrospectively reviewed. Overall 5 year survival was 25 percent. There was a trend toward improved survival in patients who received chemotherapy which did not achieve statistical significance. Sixteen patients underwent mastectomy as part of their treatment. These patients had a 48 percent 5 year survival which was significantly better than the survival in patients who did not undergo mastectomy. Furthermore, mastectomy resulted in better control of the local disease. Of 12 patients who did not undergo mastectomy, local control was initially obtained in only 2, and both of these patients suffered local recurrence within 1 year. Our data support the conclusion that mastectomy be combined with preoperative and postoperative multiagent cytotoxic chemotherapy in the treatment of inflammatory carcinoma of the breast. More precise staging may permit better prognostic stratification of patients with this highly malignant cancer.

Segmental replacement of superior vena cava with spiral vein graft

Following resection of a leiomyosarcoma, the superior vena cava (SVC) was successfully replaced by means of a spiral graft constructed from autogenous saphenous vein. This technique has previously been applied only as a bypass operation in patients with total occlusion of the SVC causing SVC syndrome. Our patient had mild SVC obstruction and absence of venous hypertension in the upper body before the operation in which segmental SVC replacement was employed. She has remained free from signs or symptoms of SVC obstruction, and graft patency was demonstrated ten months after operation. The literature concerning use of the spiral graft is reviewed, and our operative technique is described. Use of a spiral vein graft should be considered whenever large veins must be replaced.

Anterior transpericardial closure of a main bronchus fistula after pneumonectomy

A young woman sustained a penetrating wound to the right anterior chest during a vehicular accident. Septic complications led to emergency pneumonectomy followed by infection of the pleural space and disruption of the right bronchus closure. Her condition improved after creation of a pleural window for dependent drainage and gauze packing of the pleural space. Subsequently, the open bronchial stump was closed utilizing a transpericardial approach through a median sternotomy incision which permitted eventual closure of the pneumonectomy space without thoracoplasty. When the length of the bronchial stump permits its application, the transpericardial approach to postpneumonectomy bronchial fistula closure offers important advantages over conventional transpleural techniques.

Coronary artery disease following mediastinal radiation therapy

Coronary artery disease occurred in four young men (mean age 41 years) who had received curative irradiation therapy for mediastinal malignancies 12 to 18 (mean 15) years previously. None was at high risk for developing coronary artery disease by Framingham criteria. Angiography demonstrated proximal coronary artery disease with normal distal vessels. Distribution of the lesions correlated with radiation dosimetry in that vessels exposed to higher radiation intensity were more frequently diseased. Three patients had coronary bypass grafting for intractable angina and are asymptomatic at 10 to 43 months. A total of 163 patients underwent mediastinal irradiation for lymphoma or thymoma between 1959 and 1980. Among the 29 who survived 10 or more years, five (18%) developed severe coronary artery disease, implicating thoracic radiotherapy as an important risk factor. Because of the importance of mantle irradiation in the treatment of lymphomas, the prevalence of these neoplasms, and the survival patterns following treatment, many long-term survivors may be at increased risk for the development of coronary artery disease. Recognition of the relationship between radiotherapy and coronary artery disease may lead to earlier diagnosis and more timely intervention. Standard surgical treatment may be particularly beneficial because of the relative youth of most of these patients and because the proximal distribution of typical lesions increases the likelihood of complete revascularization.

Unpredictable course of small cell undifferentiated lung carcinoma

Twenty-nine patients with small cell lung carcinoma were examined as to ultrastructural morphology, stage of disease, and survival. Although all tumors met the light microscopic criteria for oat cell carcinoma, only 19 (66%) contained neurosecretory granules characteristic of this tumor. Of 12 patients undergoing pulmonary resection, five of six patients with non-neurosecretory tumors and two of six patients with neurosecretory (true oat cell) tumors survived more than 2 years. Survival of all patients with Stage I or II disease was significantly different from that of patients with Stage III disease. Stage together with ultrastructural morphology may carry important therapeutic and prognostic implications. Pulmonary resection appears to be effective treatment for certain subsets of patients with small cell undifferentiated carcinoma.

Effects of feedback on the vigilance task performance of hyperactive and hypoactive children

Hyperactive and hypoactive children show attentional deficits. An effort was made to modify their approaches to a vigilance task by varying the feedback received for correct detections and false alarms. It was expected that hyperactive children would do better when receiving knowledge of false alarms; hypoactive children would do better when receiving knowledge of correct responses. 20 hyperactive and 20 hypoactive children, aged 6 to 10 yr., were each tested under three conditions with a vigilance task: (a) feedback for correct responses (KR+), (b) feedback for false alarms (KR-), (c) no feedback NKR). Feedback was given by a tone. For the total error score, hyperactive subjects committed more errors than hypoactive ones under KR+ and fewer errors under KR-. Hypoactive children committed fewer errors under KR+ than no knowledge. Partial support for the hypothesis was obtained. Hyperactive children generally to better when given knowledge of errors; they become more cautious in responding. Hypoactive children do best when given information regarding correct responses; they become less inhibited in responding.

Effects of Feedback on the Vigilance Task Performance of Hyperactive and Hypoactive Children

Hyperactive and hypoactive children show attentional deficits. An effort was made to modify their approaches to a vigilance task by varying the feedback received for correct detections and false alarms. It was expected that hyperactive children would do better when receiving knowledge of false alarms; hypoactive children would do better when receiving knowledge of correct responses. 20 hyperactive and 20 hypoactive children, ages 6 to 10 yr., were each tested under three conditions with a vigilance task: (a) feedback for correct responses (KR+), (b) feedback for false alarms (KR -), (c) no feedback (NKR). Feedback was given by a tone. For the total error score, hyperactive subjects committed more errors than hypoactive ones under KR+ and fewer errors under KR -. Hypoactive children committed fewer errors under KR+ than no knowledge. Partial support for the hypothesis was obtained. Hyperactive children generally do better when given knowledge of errors; they become more cautious in responding. Hypoactive children do best when given information regarding correct responses; they become less inhibited in responding.

Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer

Forty-seven (39%) of 120 patients with presumably operable lung cancer were found to have metastatic tumor in mediastinal lymph nodes by mediastinoscopy. Unnecessary thoracotomy was avoided in these 47 patients. Results of anterior mediastinal node biopsy were positive in 16 (38%) of 42 patients with primary tumors of the left lung who were evaluated by anterior mediastinoscopy without resection or division of costal cartilage. Thirty-one (40%) of 78 patients with primary tumors of the right lung had positive results of mediastinal node biopsy as demonstrated by cervical mediastinoscopy. Sixty-seven percent of patients with centrally located tumors, 43% with adenocarcinoma, and 57% with undifferentiated carcinoma had mediastinal lymph node metastasis. Negative results of anterior mediastinoscopy in patients with primary tumors of the left lung predicted resectability in 25 (96%) of 26 instances. Forty-three (91%) of 47 patients with primary tumors of the right lung and negative results of cervical mediastinoscopy had resectable tumors. Anterior mediastinoscopy appears to be as accurate in the evaluation of mediastinal lymph node metastasis in left lung cancer as cervical mediastinoscopy is in the evaluation of right lung cancer.

Suitability of vigilance test data as a neurobehavioral measure of uremic status

A vigilance/continuous performance test was designed to be used for the serial testing of patients on chronic maintenance hemodialysis therapy. Correct detections, false alarms, and reaction time provided measures of an attentional deficit. A matched sample of 28 patients and 28 controls composed of nondialysands were tested. No significant differences were found between groups in correct detections and false alarms. Reaction time discriminated younger and older subjects and also dialysands and controls. The clinical usage of the test is questioned because patients resist taking the test on a serial basis every 2 wk. Motivational factors or lack of willingness to be compliant outweighed technical accomplishments.

Reversal of exertional hypotension after coronary bypass grafting

A decrease in systolic blood pressure that occurs with treadmill exercise testing may be a sign of reversible ischemic left ventricular dysfunction. To test this hypothesis, we examined retrospectively the postoperative treadmill responses of 37 patients who had exertional hypotension (end exercise systolic blood pressure less than or equal to initial preexercise levels) before coronary arterial bypass grafting. This group of 37 patients was characterized preoperatively by an abnormal exercise electrocardiogram (36 patients), multiple vessel occlusive disease (36 patients) and a normal ejection fraction at rest (32 patients). Postoperative exercise tests showed improvement in hemodynamic and electrocardiographic changes with reversal of exertional hypotension (33 patients), and conversion to a normal exercise electrocardiogram (29 patients). Coronary bypass surgery can be expected to reverse exertional hypotension in patients with symptomatic angina pectoris and evidence of ischemia in the exercise electrocardiogram.