The impact of Syme amputation in surgical treatment of patients with diabetic foot syndrome and Charcot-neuro-osteoarthropathy

INTRODUCTION

Charcot-neuro-osteoarthropathy with its severe destruction of bones remains a challenge for physicians and surgeons. The aim of the study was to characterise a patient population treated in a specialised foot care centre who underwent surgical treatment for their diabetic foot syndrome. Special attention was paid to patients who suffered from Charcot-neuro-osteoarthropathy and the impact of Syme amputation if amputation of the foot was inevitable.

MATERIALS AND METHODS

A total of 121 patients with diabetic foot syndrome and ulcerations underwent an interdisciplinary strategy for diagnostic and therapeutic procedures including MRI and surgical interventions. If peripheral arterial vessel disease was present, revascularisation by distal bypass grafting was done before the orthopaedic intervention. Some 24% showed the typical neuro-osteoarthropathy with severe bone destruction. In 8 cases amputation of the foot was performed using the Syme technique.

RESULTS

In our population the short-term results (follow-up 12 months, 20% lost to follow-up) are good, only 4% of the patients required further surgery on the same foot. In all patients with Charcot feet, plain radiographs showed the typical radiographic signs of the disease, and MRI was most helpful to detect abscess formations. The typical clinical problems of patients with Charcot disease are pointed out, and conservative and surgical treatment options are discussed. All patients with Syme amputation did well, wound healing and weight-bearing of the limb were accomplished.

CONCLUSION

The crucial diagnostic tool for decision-making in diabetic foot syndrome was MRI, which normally shows osteomyelitis with high sensitivity and specificity. In patients with Charcot-neuro-osteoarthropathy, the bone marrow oedema of the involved parts of the skeleton might misleadingly suggest the diagnosis of osteomyelitis. If amputation is inevitable in severe abscess formation combined with instability and perforation of the dislocated and destroyed bones in Charcot-neuro-osteoarthropathy, these patients might benefit from a foot amputation according to the technique Syme described. For this procedure the blood supply of the posterior tibial artery is essential. All these patients were able to walk without support. The material presented helps to generate hypotheses for further prospective studies.

[Prenatal diagnosis of hepatic hemangioendothelioma and peripartual management]

Infantile hepatic hemangioendothelioma is a benign hepatic tumor that can be associated with life-threatening perinatal complications. A 38-year-old gravida 3 para 2 was referred to our hospital with preterm labor at 33.6 gestational weeks. Fetal abdominal circumference was estimated sonographically above the 97 th percentile. Because of pathologic CTG, the fetus was delivered by caesarean section (APGAR-scores 0/0/7, pH: 7.15). After cardiopulmonary reanimation and intensive care of the fetus, the prenatally suspected hemangioma of the liver was confirmed by computer tomography. The day after, liver segments V, VI, and VII were resected because of lung compression. During the operation, reanimation was necessary two more times. Two days later, ductus arteriosus Botalli was occluded. After stabilization, the neonate was treated with prednisone because of tumor residues. If a large hyperechogenic mass in the fetal liver is seen prenatally, diagnosis of fetal hemangioma should be considered. In order to prevent serious cardiovascular complications, continual clinical surveillance is indicated.

Immunolesion of norepinephrine and epinephrine afferents to medial hypothalamus alters basal and 2-deoxy-D-glucose-induced neuropeptide Y and agouti gene-related protein messenger ribonucleic acid expression in the arcuate nucleus

Neuropeptide Y (NPY) and agouti gene-related protein (AGRP) are orexigenic peptides of special importance for control of food intake. In situ hybridization studies have shown that NPY and AGRP mRNAs are increased in the arcuate nucleus of the hypothalamus (ARC) by glucoprivation. Other work has shown that glucoprivation stimulates food intake by activation of hindbrain glucoreceptor cells and requires the participation of rostrally projecting norepinephrine (NE) or epinephrine (E) neurons. Here we determine the role of hindbrain catecholamine afferents in glucoprivation-induced increase in ARC NPY and AGRP gene expression. The selective NE/E immunotoxin saporin-conjugated antidopamine-beta-hydroxylase (anti-dbetah) was microinjected into the medial hypothalamus and expression of AGRP and NPY mRNA was analyzed subsequently in the ARC under basal and glucoprivic conditions using (33)P-labeled in situ hybridization. Saporin-conjugated anti-dbetah virtually eliminated dbetah-immunoreactive terminals in the ARC without causing nonspecific damage. These lesions significantly increased basal but eliminated 2-deoxy-D-glucose-induced increases in AGRP and NPY mRNA expression. Results indicate that hindbrain catecholaminergic neurons contribute to basal NPY and AGRP gene expression and mediate the responsiveness of NPY and AGRP neurons to glucose deficit. Our results also suggest that catecholamine neurons couple potent orexigenic neural circuitry within the hypothalamus with hindbrain glucose sensors that monitor brain glucose supply.

High-LET-induced chromosomal damage: time-dependent expression

Chromosome aberrations are routinely analysed in metaphase cells at one sampling time post-irradiation. Yet, accumulating evidence shows that radiation-induced cycle perturbations and mitotic delay influence the yield of aberrations detectable in mitosis. In extended time-course studies a drastic increase in the number of aberrations with sampling time has been observed after particle irradiation, while after the exposure to sparsely ionizing radiation a less pronounced effect has been found. This difference in the time-course of chromosomal damage is particularly important for the determination of accurate RBE values. As will be discussed, meaningful RBE values for particles can only be obtained, if cells are analysed at multiple sampling times and the complete time-course of aberrations is considered. Otherwise, particle-induced damage will be over- or underestimated. Moreover, depending on the cell system chosen for the analysis, factors like the loss of damaged cells due to apoptosis or a permanent cell cycle arrest complicate the determination of accurate RBE values based on chromosome data.

Mathematical models of radiation-induced mitotic delay: time course analysis and statistics of lesions

Detailed investigations of high and low LET radiation induced chromosome aberrations in various mammalian cell lines have shown that the registered yield of aberrations depends on cell cycle progression delays. The effect of radiation on the cell kinetics can be analyzed in terms of kinetic growth models. The method yields the number of aberrant cells and the number of aberrations as totals obtained after integration over given time-interval.

Cognitive function and fMRI in patients with multiple sclerosis: evidence for compensatory cortical activation during an attention task

Mild cognitive impairment has frequently been reported for patients in the early stages of multiple sclerosis. The aim of the present study was to measure whether altered cortical activation during a sustained attention task occurs along with limited extent of neuropsychological problems. Expanded brain activation of multiple sclerosis patients with normal motor function compared with healthy controls during a finger tapping paradigm has previously been reported. Compensatory brain activation in patients with multiple sclerosis compared with normal controls may also be observed when the subjects are performing cognitive functions. In 21 patients with clinically definite relapsing-remitting multiple sclerosis, a psychometric assessment was performed using the Wechsler Memory Scale (WMS) and the Multiple Sclerosis Functional Composite Score (MSFC). In addition, functional MRI was performed during a Paced Visual Serial Addition Task (PVSAT), a visual analogue of the Paced Auditory Serial Addition Task (PASAT). All patients were within 3 years of diagnosis and were not suffering from a relapse at the time of investigation. The multiple sclerosis patients were compared with a control group of 21 healthy volunteers matched for handedness, age, years of education and sex. With regard to psychometric results, the WMS general memory score showed statistically significant differences between patients and controls. We did not find differences for either the MSFC or the PASAT scores. A group analysis of the functional imaging data during the PVSAT revealed different activation patterns for patients compared with control subjects. In healthy volunteers, the main activation was found in the frontal part of the right gyrus cinguli (Brodmann area 32). In patients, the main activation was detected at the right hemispheric frontal cortex (Brodmann areas 6, 8 and 9). In addition, the left hemispheric Brodmann area 39 was activated. We interpret the different patterns of activation, accompanied with intact performance in a sustained attention task of our multiple sclerosis sample compared with healthy controls, as the consequence of compensatory mechanisms. This is an expression of neuronal plasticity during early stages of a chronic disease.

Immunotoxic catecholamine lesions attenuate 2DG-induced increase of AGRP mRNA

Injections of the immunotoxin, saporin conjugated to anti-dopamine-beta-hydroxylase (DSAP), into the hypothalamic paraventricular nucleus (PVH) selectively destroy norepinephrine (NE) and epinephrine (E) terminals in the medial hypothalamus and abolish glucoprivic feeding. We utilized PVH DSAP injections to examine the role of NE/E neurons in the previously reported 2-deoxy-D-glucose (2DG)-induced increases in mRNA levels for the orexigenic peptides, AGRP and NPY. Northern blot analysis revealed that DSAP lesions elevated basal but blocked 2DG-induced increases in AGRP mRNA levels. Changes in NPY mRNA were not detectable. AGRP neurons may contribute to circuitry activated by NE/E neurons for elicitation of glucoregulatory responses.

Effect of LET on the yield and quality of chromosomal damage in metaphase cells: a time-course study

PURPOSE

To investigate further the effect of linear energy transfer (LET) on the yield and quality of aberrations at different post-irradiation sampling times.

MATERIALS AND METHODS

V79 G(1)-cells were exposed to either 10.6 MeV u-1 Ne ions (360 keV microm-1) or 11.1 MeV u-1 Kr ions (3980 keV microm-1) and chromosomal damage was measured in metaphase cells at several 2-h sampling intervals up to 30 h post-irradiation. To differentiate between cells in the first and second post-irradiation cycle, the fluorescence-plus-Giemsa technique was applied.

RESULTS

In both experiments, an increase in the yield of aberrant cells as well as the number of aberrations per cell was observed in first- and second-cycle metaphases. Yet, the increase in the number of aberrations per cells was more pronounced for Kr ions and at comparable fluences Kr ions produced more aberrations than Ne ions. Because no sampling time was representative for the whole cell population, the total amount of Ne and Kr ion-induced chromosomal damage was determined by means of a mathematical approach and used for the comparison of data. Furthermore, in accordance with previous studies, LET-dependent changes in the spectrum of aberration types were detected, i.e. with increasing LET a higher fraction of chromatid-type aberrations was observed, although cells had been exposed in G1. In addition, more chromosomal breaks and less exchange-type aberrations were found.

CONCLUSIONS

The observation that cell-cycle progression is related to the amount of aberrations harboured by a cell demonstrates that the routinely applied method to measure aberration frequencies in metaphase cells at only one post-irradiation sampling time will unavoidably result in an under- or overestimation of the cytogenetic effects of particles. Consequently, for a meaningful quantification of chromosomal damage, multiple fixation regimes should be used so that the complete time-course of aberrations can be taken into account. Moreover, to avoid bias, all aberration types should be recorded and included in the analysis since the aberration spectrum changes with LET.

Acute 2DG-induced glucoprivation or dexamethasone abolishes 2DG-induced glucoregulatory responses to subsequent glucoprivation

Behavioral, neuroendocrine, and autonomic responses to glucoprivation are impaired after a glucoprivic episode. A life-threatening manifestation of this effect, known as hypoglycemia-associated autonomic failure (HAAF), occurs in diabetic patients as a result of prior inadvertent hypoglycemia resulting from insulin therapy. Glucocorticoids, which are elevated by glucoprivation, have been implicated in the pathogenesis of HAAF. The goal of the present study was to examine the effect of glucocorticoids on glucoregulatory responses in a rat model of HAAF. 2-deoxy-D-glucose (2DG; 200 mg/kg) was used to induce glucoprivation. Rats were injected with saline, 2DG, or the synthetic glucocorticoid, dexamethasone (DEX; 250 microg/rat) in the morning. Then 6 h later, rats were injected with 2DG, and their feeding and hyperglycemic responses were measured. Both 2DG and DEX in the morning eliminated glucoprivic feeding and hyperglycemic responses in the afternoon test. Epinephrine (0.3 mg/kg) administration in the afternoon elicited marked hyperglycemia in animals given 2DG that morning, demonstrating that glycogen depletion from morning glucoprivation was not responsible for the absence of the hyperglycemic response in the afternoon test. The effects of prior saline or 2DG treatment on subsequent glucoprivic feeding were also examined in adrenalectomized rats in which the source of endogenous glucocorticoids was removed. In these animals, prior glucoprivation did not attenuate 2DG-induced feeding in the afternoon test. These findings demonstrate that a single glucoprivic episode is sufficient to cause impairment in glucoregulatory responses to a second glucoprivic episode in the same day. In addition, these results strongly implicate glucocorticoids in the pathogenesis of HAAF.

Reducing the linewidth of a diode laser below 30 Hz by stabilization to a reference cavity with a finesse above 10(5)

An extended-cavity diode laser operating in the Littrow configuration emitting near 657 nm is stabilized through its injection current to a reference cavity with a finesse of more than 10(5) and a corresponding resonance linewidth of 14 kHz. The laser linewidth is reduced from a few megahertz to a value below 30 Hz. The compact and robust setup appears ideal as a portable optical frequency standard that uses the calcium intercombination line.

Immunotoxic destruction of distinct catecholamine subgroups produces selective impairment of glucoregulatory responses and neuronal activation

The toxin-antibody complex anti-d(beta)h-saporin (DSAP) selectively destroys d(beta)h-containing catecholamine neurons. To test the role of specific catecholamine neurons in glucoregulatory feeding and adrenal medullary secretion, we injected DSAP, unconjugated saporin (SAP), or saline bilaterally into the paraventricular nucleus of the hypothalamus (PVH) or spinal cord (T2-T4) and subsequently tested rats for 2-deoxy-D-glucose (2DG)-induced feeding and blood glucose responses. Injections of DSAP into the PVH abolished 2DG-induced feeding, but not hyperglycemia. 2DG-induced Fos expression was profoundly reduced or abolished in the PVH, but not in the adrenal medulla. The PVH DSAP injections caused a nearly complete loss of tyrosine hydroxylase immunoreactive (TH-ir) neurons in the area of A1/C1 overlap and severe reduction of A2, C2, C3 (primarily the periventricular portion), and A6 cell groups. Spinal cord DSAP blocked 2DG-induced hyperglycemia but not feeding. 2DG-induced Fos-ir was abolished in the adrenal medulla but not in the PVH. Spinal cord DSAP caused a nearly complete loss of TH-ir in cell groups A5, A7, subcoeruleus, and retrofacial C1 and a partial destruction of C3 (primarily the ventral portion) and A6. Saline and SAP control injections did not cause deficits in 2DG-induced feeding, hyperglycemia, or Fos expression and did not damage catecholamine neurons. DSAP eliminated d(beta)h immunoreactivity but did not cause significant nonspecific damage at injection sites. The results demonstrate that hindbrain catecholamine neurons are essential components of the circuitry for glucoprivic control of feeding and adrenal medullary secretion and indicate that these responses are mediated by different subpopulations of catecholamine neurons.

Low-resolution data analysis for low-density lipoprotein particle

The knowledge of the molecular structure of LDL, a large lipoprotein complex, is of great interest for medical investigations. Currently available LDL crystals do not diffract to high resolution and do not allow the application of standard crystallographic techniques. Additional difficulties arise because of a very dense crystal packing and the presence of several components with quite different mean densities. Several ab initio phasing methods previously reported by the authors have been successfully applied to find a crystallographic image of LDL at a resolution of 27 A. The most promising results have been obtained using direct phasing with a connectivity analysis of the electron-density maps. The current image makes it possible to discern a single particle covered by a layer of relatively high density that is asymmetrically distributed on the particle surface. It shows a partition of high and low densities inside the particle and, in particular, strips of varying density in the lipid core.

Analysis of Ar-ion and X-ray-induced chromatin breakage and repair in V79 plateau-phase cells by the premature chromosome condensation technique

PURPOSE

The premature chromosome condensation technique has been used to compare chromatin breakage and repair in noncycling V79 cells following high and low LET radiation.

MATERIALS AND METHODS

Plateau-phase V79 cells were exposed to graded doses of low energy Ar ions (LET 1233 keV/microm) and X-rays. Cells were fused to mitotic V79 cells immediately after exposure to examine initial chromatin breakage or after various time intervals of post-irradiation incubation to investigate the kinetics of chromatin break rejoining as well as the fraction of unrejoined fragments.

RESULTS AND CONCLUSIONS

For both radiation qualities an average initial number of about 2.4 excess PCC fragments per cell per Gy was found increasing linearly with dose. The distributions of PCC chromosomes plus excess fragments among cells followed Poisson statistics after X-ray irradiation, while an overdispersion of the frequencies was observed after Ar-irradiation indicating that a single particle traversal through a cell nucleus can produce multiple chromatin lesions. Moreover, for both radiation types the rejoining of excess fragments has been examined. Both data sets could be fitted well to first-order kinetics with a single component. Despite similar rates of rejoining cellular repair was noticeably less effective for Ar ions than for X-rays. While after 10 h of post-irradiation incubation 60% of Ar ion induced excess fragments remained unrejoined, only 14% of X-ray-induced lesions were not rejoined. Furthermore, comparison of the residual number of excess PCC fragments with recently published data on the yield of chromosome aberrations in first post-irradiation metaphases shows that for both radiation types more aberrations are detected in interphase than in metaphase cells. Yet, for comparable doses this difference is more pronounced for Ar ions indicating that scoring of high LET induced aberrations in metaphase cells might result in a significant underestimation of the produced damage.

Quantitative assessment of ventricular function in children with single ventricles using the Doppler myocardial performance index

Assessment of ventricular function in patients with functionally single ventricles and unusual ventricular geometry is difficult. The Doppler myocardial performance index (MPI) may provide a method of assessing function in these patients. The purposes of this study were to compare the MPI in normal children and in children with a functionally single ventricle, and to compare the MPI in patients with single ventricles before and after bidirectional cavopulmonary anastamosis (BCPA). Echocardiograms of all patients who underwent BCPA between January 1994 and December 1998 were reviewed before and after surgical palliation. Age-matched normal subjects (n = 30) served as controls. The MPI was calculated from Doppler tracings of ventricular inflow and outflow. Of the 60 patients with single ventricles who underwent BCPA, 41 had adequate preoperative Doppler studies to allow calculation of the MPI, and 21 of 41 had adequate studies before and after BCPA. The MPI was higher in patients with single ventricles than in normal controls (0.67 +/- 0.14 vs 0.32 +/- 0.10, p < 0.001). There was no significant difference in the MPI in patients with single ventricles before and after surgery (0.70 +/- 0.16 vs 0.66 +/- 0.15). However, patients who had a BCPA at < 1 year of age had a significant decrease in the MPI after surgery (0.71 +/- 0.10 vs 0.61 +/- 0.11, p = 0.01). Compared with controls, the MPI was significantly higher in patients with single ventricles suggesting an altered hemodynamic state consistent with decreased ventricular function. The MPI decreased in patients who underwent BCPA at < 1 year of age, suggesting an improvement in ventricular function. The MPI provides an objective method of assessing and following ventricular function in patients with single ventricles that is independent of ventricular geometry.

Repeated 2-deoxy-D-glucose-induced glucoprivation attenuates Fos expression and glucoregulatory responses during subsequent glucoprivation

A condition of reduced responsiveness to hypoglycemia, known as hypoglycemia-associated autonomic failure (HAAF), occurs in diabetic patients in the wake of a prior hypoglycemic episode. This condition suggests that hypoglycemia alters central glucose-sensing mechanisms. This experiment examined the effects of repeated 2-deoxy-D-glucose (2DG)-induced glucoprivation on subsequent 2DG-induced feeding and hyperglycemic responses in rats. Fos immunoreactivity (ir) in adrenal medulla and brain sites involved in these responses was also examined. Rats were injected daily for 10 days with 2DG (200 mg/kg) or saline (0.9%) or were handled. On day 11, rats were injected with 2DG (200 mg/kg). After injection, food intake was measured in one group. In another group, food was withheld, and multiple blood samples were collected for glucose determination. In a third group, food was withheld, and rats were killed after 2 h for evaluation of Fos-ir. Prior repeated glucoprivation reduced subsequent feeding and hyperglycemia responses to 2DG to baseline levels. Double-label immunohistochemistry showed that Fos-ir was reduced or abolished in catecholamine cell groups A1, A1/C1, C1, C3, and A6 and in the paraventricular nucleus of the hypothalamus and adrenal medulla. In other brain sites, 2DG-induced Fos-ir was diminished or unaffected by prior glucoprivation. Sites in which Fos-ir was abolished have been implicated previously in glucoprivic control of feeding and adrenal medullary secretion. Therefore, the present findings may identify crucial neuroanatomical sites that are altered by prior glucoprivation and that mediate some of the physiological deficits observed in HAAF.

Usefulness of the preoperative tricuspid/mitral valve ratio for predicting outcome in pulmonary atresia with intact ventricular septum

Although tricuspid valve z-scores have been used to predict outcome in pulmonary atresia with intact ventricular septum, they are statistically generated from local populations, and widespread generalization may not be appropriate. To determine if there are echocardiographic predictors of outcome that can be universally used, the records of all infants with this diagnosis since 1988 were reviewed for age, weight, type of surgery, and outcome. Preoperative and follow-up echocardiograms were reviewed for valve diameter and z-scores, and valve ratios were calculated. Thirty-six patients were divided into 2 groups: group 1 included 23 infants who had a successful biventricular repair; group 2 included the remaining 13 infants who did not have a successful repair. Preoperatively, both groups had similar ages, pulmonary, aortic, and mitral z-scores, and pulmonary/aortic ratios, but the patients in group 2 had significantly lower weight (3.5 +/- 0.6 vs 2.9 +/- 0.5 kg), tricuspid z-scores (-0.7 +/- 1.5 vs -2.3 +/- 1.2), and tricuspid/mitral ratios (0.8 +/- 0.2 vs 0.5 +/- 0.1). At similar follow-up, both groups of patients had similar weight, aortic and mitral z-scores, and pulmonary/aortic ratios, but group 2 infants had significantly lower pulmonary and tricuspid z-scores and tricuspid/mitral ratios. Compared with the preoperative echocardiograms, group 1 had significant increases only in pulmonary z-scores, and pulmonary/aortic and tricuspid/mitral ratios. Group 2 had no significant change in any echocardiographic variable. The tricuspid/mitral ratio was >0.5 in all group 1 infants, and in 6 of 13 group 2 infants (2 sepsis deaths, 4 palliations). Compared with a tricuspid valve z-score >-3, a tricuspid/mitral ratio >0.5 was a better predictor of biventricular repair. Thus, infants who have a successful biventricular repair have significantly greater preoperative weight, tricuspid valve z-scores, and tricuspid/mitral valve ratios. A tricuspid/mitral ratio >0.5 was the best predictor of a biventricular repair.

Beliefs about voices and their effects on coping strategies

Cognitive behavioural techniques are increasingly used as adjuncts to medication in the treatment of auditory hallucinations for people with schizophrenia. There are now literally hundreds of nurses trained in the use of cognitive behavioural interventions for psychosis. However, there is still disagreement about the nature of the cognitive processes that lead to deficits or biases in patients' processing of information about their psychotic experiences. Using Chadwick & Birchwood's Beliefs About Voices Questionnaire (BAVQ), the investigator collected data regarding voices from a sample of men and women being treated for schizophrenia by secondary mental health services. The investigator then carried out a cross-lagged panel analysis of the data. The investigator found, as predicted, positive relationships between a resistive coping style and an attribution of malevolence to voices, and between an engaging coping style and an attribution of benevolence to voices. Coping and attributional styles were not necessarily stable over time. There was a non-significant difference between women's and men's attributions and coping styles. There was less fluctuation over time in the women's scores on the BAVQ. This research shows that one cannot assume that either coping or attributional style becomes more stable over time. However, while there are strong relationships between attributions and coping styles, and particularly between malevolence and resistance and benevolence and engagement, these relationships are not necessarily mutually exclusive and some people in the study believe their voices to be both malevolent and benevolent. These findings suggest that clinicians need to make a very careful assessment of attribution and coping with regard to hallucinations and that systematic reassessment is very important. Further research is necessary in both the phenomenology of attribution and coping, but also to relate these variables to other aspects of schizophrenic illnesses.

An unusual variant of total anomalous pulmonary venous connection with varices and multiple drainage sites

Total anomalous pulmonary venous connection (TAPVC) is an uncommon cardiac anomaly that has also rarely been associated with esophageal atresia. We report an unusual case of esophageal atresia with TAPVC with several varices and multiple drainage sites into the superior vena cava and portal vein.

What is the yield of screening echocardiography in pediatric syncope?

OBJECTIVE

To determine the yield of screening echocardiography in the evaluation of pediatric syncope.

DESIGN

All patients diagnosed with syncope from January 1993 to January 1999 were identified and their records were reviewed for age, weight, sex, year of presentation, personal and family history, physical examination, and cardiac diagnostic testing. Cardiac defects were identified by reviewing echocardiograms and reports.

RESULTS

The 480 patients (268 females) ranged in age from 1.5 to 18.0 years old and ranged in weight from 10.3 to 113.6 kg. Final diagnoses included noncardiac causes in 458, long QT syndrome in 14, arrhythmias in 6, and cardiomyopathy in 2. An abnormal history, physical examination, or electrocardiogram identified 21 of the 22 patients with a cardiac cause of syncope. Of the 322 (67%) echocardiograms performed, abnormalities were detected in 37. These abnormalities included 26 minor valve anomalies, 7 hemodynamically insignificant shunt lesions, 2 mildly decreased left ventricular shortening fractions, and 2 cardiomyopathies. Only the 2 cardiomyopathies were considered to be potential causes of syncope, and in both cases, the electrocardiogram was markedly abnormal. A similar percentage of echocardiograms were ordered during the first and last 3 years of the study (61% vs 71%).

CONCLUSION

History, physical examination, and electrocardiography provide a screening protocol that allows the identification of a cardiac cause of syncope in the overwhelming majority of pediatric patients. In the absence of a positive screen result, the echocardiogram does not contribute to the evaluation of syncope in children. We speculate that primary care providers and pediatric cardiologists continue to use echocardiography because of the paucity of data regarding its value in pediatric syncope. However, this study shows little benefit of screening echocardiography and should discourage its routine use.

Localization of hindbrain glucoreceptive sites controlling food intake and blood glucose

Feeding and blood glucose responses to local injection of nanoliter volumes of 5-thio-D-glucose (5TG), a potent antimetabolic glucose analogue, were studied at 142 hindbrain and 61 hypothalamic cannula sites. A site was considered positive if 5TG elicited at least 1.5 g more food intake or a hyperglycemic response at least 25 mg/dl greater than the respective responses elicited by vehicle injection in the same rat. Of 61 hypothalamic cannula sites tested, none were positive for blood glucose and only one was positive for feeding. Increasing the 5TG dose to 48 ug did not produce additional positive results at hypothalamic sites. In contrast, 66 hindbrain sites were positive for feeding and 49 were positive for blood glucose, with 33 of these being positive for both responses. The distribution of positive sites for feeding and hyperglycemia overlapped almost completely. Positive sites were concentrated in two distinct zones: one in the ventrolateral and one in the dorsomedial medulla. In both locations, the glucoreceptive areas extended approximately from the level of the area postrema (AP) to the pontomedullary junction. Glucoreceptive zones were co-distributed with epinephrine cell groups C1-C3, suggesting that epinephrine neurons may be important components of the neural circuitry for glucoregulation. Localization of glucoreceptive sites will facilitate positive identification of glucoreceptor cells and the direct analysis of the neural mechanisms through which they influence food intake and metabolic responses.