Blunt chest trauma in the elderly

Significant differences were identified between a group of elderly patients (65 years and older) and a nonelderly group both with blunt thoracic trauma. There was a lower incidence of elderly patients presenting in shock; however, cardiopulmonary arrest at arrival was more frequent in this group. Although the types of complications were similar in both populations, the morbidity and mortality rates were higher in the elderly. A high index of suspicion must be generated for an elderly patient who has sustained blunt chest trauma. An aggressive diagnostic and therapeutic approach may lead to a decrease in the high morbidity and mortality rates in the elderly.

Reversible ATP-dependent inactivation of glycerolphosphate acyltransferase from rat adipose tissue

Microsomal glycerolphosphate acyltransferase from rat adipose tissue is shown to be inactivated with time upon incubation with ATP. The inactivation can be observed in postmitochondrial supernatant as well as in washed microsomes. However, the effect is more pronounced upon addition of the cytosolic fraction. This activity is specific for ATP, is dependent on the nucleotide concentration, and is prevented when ATP is substituted by beta,gamma-methylene-ATP. Some protection is provided by amiloride but not by EGTA or cAMP-protein kinase inhibitor. Also, the level of enzyme inactivation is not modified by addition of cAMP-dependent protein kinase and its substrates. Inactivated glycerol-phosphate acyltransferase from ATP-treated microsomes can be reactivated by incubation with partially purified protein phosphatase from rat liver. These results suggest the existence in adipose tissue of a protein kinase (cAMP independent) that may be involved in the regulation of glycerolphosphate acyltransferase.

Radiation damage to glucose concentrating capacity and cell survival in kidney tubule cells: effects of fractionation

The glucose concentrating capacity of cultured LLC-PK1 kidney epithelial cells has been measured after single and fractionated doses of X-rays. Steady-state glucose concentrating capacity (ratio of glucose concentration inside to outside cell) can be measured using radiolabelled analogues of glucose which are actively transported but not metabolized. These cells can be stimulated to increase their glucose concentrating capacity (up-regulation) by a reduction in the glucose concentration of the growth medium. However, after X-ray irradiation the cells have a reduced capacity to respond to up-regulation. This effect can be measured 7 days after irradiation and before radiation-induced cell killing affects the cell population. The previously reported radiosensitivity of this function to single doses of X-rays (in the range 1-16 Gy) was confirmed. Surprisingly, no significant sparing of this effect could be measured by fractionation of the X-ray dose into two or four fractions. However, the cells showed a significant fractionation effect if clonogenic survival was measured using the standard cell survival assay. These early effects have different fractionation response from the later phases of tissue damage, measured months to years after irradiation, which do show sparing due to fractionation and are thought to be mainly due to changes in cell survival. The lack of sparing by fractionation to the functional damage may suggest a different target from that which determines cell survival. These results support the hypothesis that radiation damages cellular functions, separately from cell replication.

A randomized trial of tamponade or sclerotherapy as immediate treatment for bleeding esophageal varices

Sengstaken-Blakemore tamponade is used for the initial control of bleeding esophageal varices (BEV), although it is known to be potentially dangerous. Sclerotherapy has been shown to be effective in the treatment of BEV. This trial has been designed to evaluate comparatively the effectiveness of both procedures in the initial control of the hemorrhage. Forty-three patients with BEV were included in the trial. Twenty patients (group SB) were treated by tamponade. Twenty-three patients (group ST) were treated by sclerotherapy by means of a simple technique. During the first 24 hours, hemostasis was obtained in 16 of the SB patients and in all 23 of the ST patients (p less than 0.05). At seven days, nine SB patients and 19 ST patients were free of hemorrhagic relapse (p less than 0.05). By stratifying in relation to hepatic failure, the difference was greater (p less than 0.005) if patients with Child's A classification were excluded. It is concluded that sclerotherapy should be undertaken in almost every instance at the same moment that diagnosis is made, bypassing the intermediate step of tamponade.

The dependency ratio and optimum population growth. The total utility case

"This paper examines the effects of introducing a variable dependency ratio in Dasgupta's (1969) model. We consider a case in which the probability of dying as well as the rate of participation in the labor force change with age. It is shown that the inclusion of those realistic demographic features slows down the optimal rate of population growth and increases the rate of consumption. In spite of the reduction in the rate of population growth, this rate can still be positive. The sensitivity of the solutions to changes in the demographic parameters of the model is examined."

Management of major tracheobronchial ruptures in patients with multiple system trauma

Major tracheobronchial injury presents special problems in the context of multiple system trauma. A 14-year review of a clinical experience revealed eight patients who had operative repair of major bronchial or intrathoracic tracheal injuries. The diagnosis was suspected by subcutaneous emphysema, and especially by persistent pneumothorax or a significant air leak. Bronchoscopy confirmed the diagnosis in all patients before thoracotomy. All eight patients had multiple system injuries. All five with abdominal injuries were hypotensive at admission and underwent celiotomy before thoracotomy. The decision to perform thoracotomy or celiotomy first in patients with major tracheobronchial injuries and concomitant abdominal trauma must be individualized. If both injuries are recognized simultaneously and the patient is hemodynamically unstable but has adequate oxygenation and ventilation, the celiotomy can be performed first. On the contrary, if oxygenation and ventilation are the most threatening problems in a hemodynamically stable patient despite evidence of hemoperitoneum, the bronchial repair should have priority.

Clinical significance of radionuclide angiographically-determined abnormalities following acute blunt chest trauma

Abnormalities of right and left ventricular ejection fraction and segmental wall motion may be detected by radionuclide angiography (RNA) following blunt chest trauma. Of 111 patients with blunt chest trauma who were admitted to a large regional shock trauma center and underwent combined first-pass and equilibrium gated RNA, abnormalities were present in 40 (36%). These abnormalities were confined to the right ventricle in 33 patients. There was a positive association between RNA abnormalities and the presence of right bundle branch block (10 of 40, p less than 0.05) and a negative association between RNA abnormalities and the finding of rib fractures (6 of 40, p less than 0.05). The in-hospital death rate of these patients was low (3 of 40 patients with an abnormal RNA and 2 of 71 patients with a normal RNA). Follow-up RNA was performed at 10 +/- 4 days in 26 of the 40 patients with initially abnormal scans, and 22 (85%) of the 26 had reverted to normal. Thus although RNA abnormalities appear common following blunt chest trauma, among patients who survive for more than 24 hours and who undergo subsequent RNA, the complication rate is low despite an abnormal scan. We conclude that routine RNA adds little to clinical management following acute blunt chest trauma.

Effects of D-penicillamine on mononuclear cells in vitro

D-penicillamine (D-pen) inhibited pokeweed mitogen-induced plaque-forming cell (PFC) response in a dose-dependent manner. This inhibition was irreversible as preincubation for a few hours with the drug followed by washes still caused suppression of the PFC response. Pretreatment of the different mononuclear cell populations with D-pen for short periods (2-24 h) showed that both macrophages (Mo) and B lymphocytes were affected by the drug. By contrast T cells were resistant. Mo appears to be more susceptible to D-pen than B cells, and in the case of drug-treated Mo, the response was restored completely with the addition of 20% fresh Mo. Our results show that D-pen, without exogenous Cu2+, inhibits the polyclonal immunoglobulin secretion by human mononuclear cells in vitro due to a strong effect on both Mo and B cells. This may explain the decrease in serum immunoglobulin levels seen in patients with rheumatoid arthritis undergoing this therapy.

Recovery from potentially lethal damage and recruitment time of noncycling clonogenic cells in 9L confluent monolayers and spheroids

Cells that have been grown as multicell tumor spheroids exhibit radioresistance compared to the same cells grown in monolayers. Comparison of potentially lethal damage (PLD) repair and its kinetics was made between 9L cells grown as spheroids and confluent monolayers. Survival curves of cells plated immediately after irradiation showed the typical radioresistance associated with spheroid culture compared to plateau-phase monolayers. The dose-modification factor for spheroid cell survival is 1.44. Postirradiation incubations in normal phosphate-buffered saline (PBS), conditioned media, or 0.5 M NaCl in PBS reduced the differences in radiosensitivity between the two culture conditions. Postirradiation treatment in PBS or conditioned medium promoted repair of potentially lethal damage, and 0.5 M NaCl prevented the removal of PLD and allowed the fixation of damage resulting in lower survival. Survival of spheroid and monolayer cells after hypertonic NaCl treatment was identical. NaCl treatment reduced Do more than it did the shoulder (Dq) of the survival curve. PLD repair kinetics measured after postirradiation incubation in PBS followed by hypertonic NaCl treatment was the same for spheroids and for plateau-phase monolayers. The kinetics of PLD repair indicates a biphasic phenomenon. There is an initial fast component with a repair half-time of 7.9 min and a slow component with a repair half-time of 56.6 min. Most of the damage (59%) is repaired slowly. Since the repair capacity and kinetics are the same for spheroids and monolayers, the radioresistance of spheroids cannot be explained on this basis. Evidence indicates that the time to return from a Go (noncycling G1 cells) state to a proliferative state (recruitment) for cells from confluent monolayers and from spheroids after dissociation by protease treatment may be the most important determinant of the degree of PLD repair that occurs. Growth curves and flow cytometry cell cycle analysis indicate that spheroid cells have a lag period for reentry into a proliferative state. Since plating efficiency remains high and unchanging during this period, one cannot account for the delay on the basis of the existence of a large fraction of Go cells which are not potentially clonogenic. The cell cycle progression begins in 6-8 h for monolayer cells and in 14-15 h for spheroids. It is hypothesized that the slower reentry of spheroid cells into a cycling phase allows more time for repair than for the rapidly proliferating monolayer cells.

Mediastinal tumors presenting as spontaneous hemothorax, simulating aortic dissection

The usual causes of hemomediastinum and hemothorax include chest trauma, rupture of an aortic aneurysm or aortic dissection. We report two patients who presented with a clinical picture of aortic dissection. In both patients, the chest radiograph revealed anterior mediastinal masses. Aortic dissection could not be excluded on the basis of the chest radiograph, and additional investigation by thoracic aortography was performed. The tumors had undergone spontaneous bleeding into the mediastinum and the pleural space, presumably causing the patients pain. The interesting and unusual causes of spontaneous hemomediastinum and hemothorax are reviewed.

Adipose tissue glyceride synthesis in patients with hyperapobetalipoproteinemia

Adipose tissue was obtained at thoracotomy in five control patients with valvular heart disease, all of whom were free of coronary artery disease and all of whom were normolipidemic with normal low density lipoprotein apolipoprotein B levels, and eight patients with coronary artery disease, all of whom had hyperapobetalipoproteinemia. In both groups, the rates at which linoleic acid and palmitic acid were incorporated into diglyceride and triglyceride were determined in vitro. The data indicate that fatty acid incorporation into adipose tissue glycerides was twice as rapid in controls as in patients with hyperapobetalipoproteinemia. By contrast there was no difference between the groups in the rate of net lipolysis of adipocyte glyceride. The data at hand do not establish the mechanism responsible for the difference in synthesis between normal subjects and patients with hyperapobetalipoproteinemia, but this may explain the delayed chylomicron triglyceride clearance previously observed in the disorder.

IgG4 in human colostrum and human milk: continued local production or selective transport from serum

Colostrum, mature milk, and paired plasma samples were obtained from 10 postpartum women who had not been previously studied. The geometric mean concentration of IgG4 in colostrum (3.3 micrograms/ml) was similar to the mean concentration in mature milk (3.0 micrograms/ml). The arithmetic mean for the percent of IgG = IgG4 was 10.3 +/- 3.3% for colostrum, 10.3 +/- 3.1% for mature milk, 2.6 +/- 0.3% for early plasma, and 1.7 +/- 0.3% for later plasma. Local mammary production of immunoglobulin was determined by subtracting the estimated serum contribution from the measured concentration in colostrum or milk. Evidence for local mammary production of IgG4 was found in 5 of 10 colostrum samples and 8 of 10 mature milk samples. These observations indicate that the previously observed selective enrichment of IgG4 in colostrum is also true for mature milk. These are the first studies suggesting continued local production of any immunoglobulin other than IgA in mature human breast milk.

MR imaging of traumatic diaphragmatic rupture

The diagnosis of traumatic rupture of the diaphragm may remain elusive despite a variety of imaging options including CT and sonography. Direct sagittal and coronal magnetic resonance images provided a definitive diagnosis of left diaphragmatic rupture with herniation of colon into the thorax.

Morphology of the lumbar vertebral canal

In a series of 215 anteroposterior X-ray films, a study was made of the horizontal distance between the pedicles of each lumbar vertebra, first of all sequentially, describing the morphology adopted by the lateral limits of the canal, and secondly determining the absolute value for each level separately and in relation to the variables of sex and age. The absolute value of this distance at each level is related to the thickness of the pedicles and the width of the vertebral bodies of L3 and L4. The values obtained were tested with the appropriate statistics in each case.

Complications of clear lens extraction in axial myopia

Clear lens extraction is a refractive surgery used to compensate axial myopia. Formerly, intracapsular lens extraction was performed, but the present surgical method is extracapsular lens extraction or phacoemulsification. Clear lens extraction is becoming controversial because of the danger of complications. We retrospectively reviewed the postoperative complications in 33 eyes of 20 patients who underwent clear lens extraction at other institutions between 1966 and 1984. Twelve patients (60%) had motility disturbances. Eight (24%) of 33 eyes suffered secondary glaucoma; ten (30%), retinal detachment; 12 (36%), lens remnants in the pupillary space; and six (18%), blindness caused by clear lens extraction or by additional surgery performed by us while attempting to improve a poor prognosis. Clear lens extraction appears to be contraindicated in the young, in those with axial diameters greater than 29 mm, and in those presenting with peripheral chorioretinal degeneration. Moreover, clear lens extraction does not avoid the progression of myopia at the posterior segment. We suggest the use of safer, noninvasive, reversible alternatives.

Low density lipoprotein (LDL) inhibits histamine release from human mast cells

We examined the effect of low density lipoprotein (LDL) on histamine release from purified human lung mast cells. LDL inhibited anti-IgE- induced histamine release in a dose-dependent manner, with 100 micrograms/ml LDL-protein inhibiting histamine release by 53 +/- 8% (mean +/- SEM); half-maximal inhibition occurred at 40-80 micrograms/ml. LDL also inhibited calcium ionophore A23187-induced histamine release in a dose-dependent manner, with 1 mg/ml of LDL inhibiting histamine release by 83 +/- 9%; half maximal inhibition occurred at 220-280 micrograms/ml. Inhibition by LDL was time-dependent: half-maximal inhibition of anti-IgE- induced histamine release by LDL occurred at 30-50 minutes of incubation. The inhibitory effect of LDL was independent of buffer calcium concentrations (0-5 mM) or temperature (0-37 degrees C). These data are consistent with a newly defined immunoregulatory role for LDL.

Role of CT in excluding major arterial injury after blunt thoracic trauma

The role of CT in the diagnosis of major vascular rupture following blunt decelerating chest trauma is controversial. Its value in excluding major arterial injury has not yet been determined. During a 12-month period we obtained dynamic enhanced thoracic CT studies in 20 patients with blunt decelerating thoracic trauma who had abnormal or equivocal mediastinal contours on chest radiographs. In all cases diagnosis was confirmed by either digital subtraction (18 patients) or conventional thoracic angiography (two patients). CT scans showed evidence of direct aortic injury in three patients and evidence of mediastinal hematoma in five others. Four of these eight patients had major arterial injury verified angiographically and at surgery. In two patients the CT scan was considered equivocal; both patients had normal thoracic angiograms. CT excluded direct vascular injury or mediastinal hematoma in 10 patients. All 10 had normal thoracic angiograms. This preliminary study suggests that, in patients sustaining blunt decelerating thoracic trauma, thoracic CT may be more valuable than chest radiography in excluding major vascular injury and, in some cases, may reduce the need for thoracic angiography.

Prospective study of scheduled withdrawal from nortriptyline in children and adolescents

Thirty 6- to 16-year-old subjects were gradually tapered from their maintenance dose of nortriptyline while being monitored for withdrawal effects. Five subjects had brief gastrointestinal distress that did not require the administration of an extra dose. The results of this open study suggest that scheduled tapering of nortriptyline will preclude withdrawal symptoms in most pediatric patients.

Blunt thoracic trauma. Analysis of 515 patients

A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the absence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients. A high index of suspicion for blunt chest injury occurring in blunt trauma, coupled with an aggressive diagnostic and therapeutic approach, remains the cornerstone of treatment to minimize the morbidity and mortality of such injuries.

Spontaneous pulmonary torsion

A patient with systemic manifestations of sepsis after above-knee amputation developed massive left pulmonary atelectasis and pneumonia. These persisted despite repeated bronchoscopies. At thoracotomy, 180 degrees torsion of the left lung was found. The patient improved temporarily but died later of sepsis, probably related to severe hip osteomyelitis.