Extravesical ureteral reimplantation: results in 128 patients

PURPOSE

We evaluated the results of extravesical ureteral reimplantation in children.

MATERIALS AND METHODS

We reviewed the records of 128 children (174 ureters) who underwent ureteral reimplantation via extravesical techniques. Primary vesicoureteral reflux was the most common diagnosis (73 patients).

RESULTS

The extravesical technique produced a successful result in all patients (no reflux or obstruction). The 2 complications included postoperative urosepsis and transient urinary retention.

CONCLUSIONS

Extravesical ureteral reimplantation is a reliable procedure with predictable results comparable to those of more traditional intravesical techniques.

Clinical, hematologic, and biochemical features of a syndrome in Bernese mountain dogs characterized by hepatocerebellar degeneration

Seven related Bernese Mountain Dogs developed a syndrome Characterized by progressive cerebellar and hepatic disease. Clinically, stiffness in the hind limbs, mild incoordination, and a slight head tremor were first noticeable when pups were 4 to 6 weeks old. The condition progressed, causing pups to assume a wide-based stance. Other signs included head bobbing, spontaneous nystagmus, and, finally, paresis. Hematologic findings included leukocytosis with a left shift; normocytic, normochromic anemia; hypoproteinemia, low serum creatinine, and urea nitrogen concentrations; excessive fasting plasma ammonia concentration; and an increase in concentration of serum bile acids. Portal venography performed on 1 dog revealed a small liver and extensive extrahepatic varicosities. Necropsy revealed cerebellar hypoplasia, nodular liver, extensive abdominal varicosities, and ascites. Histologically, degeneration and depletion of Purkinje's cells and vacuolation, degeneration, and nodular regeneration of hepatic tissues were evident. Preliminary analysis of the pedigree was suggestive of an autosomal recessive pattern of inheritance.

Dexamethasone and prostaglandin E2 modulate T-cell receptor signaling through a cAMP-independent mechanism

One possible explanation for the link between stress and increased incidence of infection can be attributed to concomitant increases in levels of glucocorticoids (GS) and prostaglandin E2 (PGE2), both of which possess potent immunoregulatory activities. We have previously demonstrated that concentrations of PGE2 and the synthetic glucocorticoid, dexamethasone (DEX), which individually do not inhibit human T-cell responsiveness to anti-CD3 monoclonal antibody (mAb), act synergistically to inhibit IL-2 secretion and subsequent T-cell proliferation. In the present paper, we demonstrate that treatment of anti-CD3 mAb-stimulated T-cells with low (10(-8) and 10(-9) M) concentrations of DEX and PGE2 results in the inhibition of steady-state levels of IL-2 mRNA. Initial studies to elucidate the biochemical mechanisms involved indicate that the inhibitory effects of DEX and PGE2 cannot be correlated with increased levels of intracellular cAMP or the induction of apoptosis. However, the data indicate that DEX and PGE2 when added together interrupt anti-CD3 mAb-induced tyrosine phosphorylation of substrate proteins. Furthermore, the synergistic effect of DEX and PGE2 is mimicked by agonists for the cAMP-independent EP3 subtype of the PGE2 receptor. These data suggest that DEX and PGE2 elicit cAMP-independent signaling pathways which interact to inhibit the T-cell receptor-linked signal transduction cascade in anti-CD3 mAb-stimulated T-cells.

Apparent idiopathic hyponatremia in an ambulatory geriatric population

OBJECTIVES

The purpose of this descriptive analysis is to demonstrate that among older patients with hyponatremia, there is a subset with apparent hyponatremia of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) type, which appears associated with the aging process. A retrospective chart review was done to identify patients with hyponatremia and to classify them into non-SIADH, SIADH, and idiopathic categories.

DESIGN

The participants were the ambulatory population of The Mount Sinai Hospital's outpatient geriatric clinic. Pertinent data generated during the antecedent 24 months were collected from outpatient charts and included sets of laboratory values (consisting of one sodium, glucose, BUN and creatinine level), age, sex, race, clinical history, present diagnosis, medications, and prescribed diets for each patient in the total population.

RESULTS

Patients demonstrating hyponatremia with serum sodium levels of less than 135 mEq/L were identified from the total population and were further divided into SIADH and non-SIADH etiologies. The SIADH patients were then subdivided into known etiology SIADH and apparent idiopathic SIADH. In an ambulatory geriatric population of 405 subjects, 46 had hyponatremia, with SIADH the apparent cause in 27. Of the SIADH population, seven patients were considered to have idiopathic SIADH. An apparent predilection for development of this syndrome was observed among non-black patients and the old old.

CONCLUSIONS

The results support the hypothesis that aging is a risk factor for the development of SIADH-like hyponatremia in a subset of older patients who do not have an apparent underlying etiology. Thus, aging may be an independent etiology for the development of hyponatremia.

Security considerations for present and future medical databases

In this paper we consider the security of medical databases. We give an overview of the security problems and the possible available mechanisms for the prevention of security compromises. Many of the security problems are common to all databases. However, the problem of data inference from statistical queries is particularly pertinent to medical databases and consequently we treat this problem in more detail. The paper concludes with a proposal for a Security Subsystem in a database management system.

Induction of c-fos expression following stimulation of pulmonary neuroendocrine cell proliferation by alterations in CO2/O-2 concentration

Pulmonary neuroendocrine (PNE) cells were harvested and cultivated from peripheral lung tissue of 15 day old fetal hamsters under selective growth conditions, including a 10% CO2 atmosphere. Following 24 h of serum starvation under 10% CO2, PNE cells placed in a 5% CO2 atmosphere failed to proliferate over the next 24 h, while cells kept at 10% CO2 showed a 2.7-fold increase in cell number. Addition of nicotine to the cell culture medium resulted in an additional concentration-dependent increase in cell number under a 10% CO2 atmosphere, while nicotine did not stimulate the proliferation of cells maintained at 5% CO2. The nicotinic receptor antagonist hexamethonium completely blocked the stimulatory effect of nicotine on cell growth. As a first step towards determining the molecular mechanisms regulating the mitogenic stimulation of PNE cells by alterations in CO2/O-2 and nicotine, cells that had been serum starved under a 10% CO2 atmosphere for 24 h were removed from the incubator and either left untreated or treated with 1 mu M nicotine under ambient air. The cells were then returned to either a 5% or 10% CO2 atmosphere. Removal of the cells from a 10% CO2 environment and subsequent reintroduction to a high CO2 concentration resulted in a 3- to 4-fold increase in c-Sos RNA expression within 15-30 min upon return to the cell culture incubator. c-fos RNA levels their decreased back to control values by 1 h. Reintroduction into a 5% CO2 atmosphere, which failed to stimulate cell growth in the proliferation assay, caused only a 2-fold increase in the levels of c-fos transcripts. The CO2-mediated increases in c-Sos transcripts were observed both in the presence and absence of nicotine, suggesting that the effects of nicotine were mediated through a fos-independent pathway. Neither the alterations in CO2/O-2 concentration or treatment with nicotine altered the levels of c-myc or c-jun gene transcripts. Nicotine thus acts indirectly but synergistically with high CO2 concentrations to stimulate PNE cell proliferation.

Changes in plasma endothelin-1 levels reflect clinical response to beta-blockade in chronic heart failure

Plasma levels of endothelin-1 are elevated in patients with chronic heart failure; however, it is unknown whether changes in plasma endothelin-1 levels accurately reflect clinical response to therapy in these patients. To determine this, we measured plasma endothelin-1 in addition to functional, hemodynamic, and other neurohormonal parameters as part of a double-blind, placebo-controlled study of the beta-blocker vasodilator carvedilol in patients with moderate to severe chronic heart failure. Patients were assigned (2:1 randomization) to receive carvedilol (25 mg twice daily, n = 10) or placebo (n = 5) for 14 weeks, with evaluations made before and after therapy. Compared to patients receiving placebo, patients receiving carvedilol improved significantly as assessed by the parameters described. These changes were paralleled by significant falls in endothelin-1 with carvedilol (-2.1 + 3.8 pg/ml) in comparison to placebo (2.2 + 3.9 pg/ml; p < 0.05 for between-group differences). Changes in endothelin-1 after treatment in both groups correlated significantly with changes in symptom severity, New York Heart Association class, 6-minute walk distance (r = 0.64 to 0.80; p < 0.05), hemodynamic parameters (ejection fraction, right atrial pressure, pulmonary artery diastolic pressure, pulmonary wedge pressure, right atrial pressure, and stroke volume index; r = 0.54 to 0.86; p < 0.05), and neurohormonal parameters (serum aldosterone and plasma norepinephrine (r = 0.74 to 0.76; p < 0.05). By stepwise regression analysis, change in endothelin-1 was an independent, noninvasive predictor of functional and hemodynamic responses to therapy in these patients. These findings suggest that endothelin-1 accurately reflects functional, hemodynamic, and neurohormonal responses to beta-blocker therapy in patients with congestive heart failure. Measurement of endothelin-1 may therefore be a useful, noninvasive approach to the evaluation of clinical response to drug therapy in these patients.

Preparation of social workers for serving individuals with developmental disabilities: a brief report

A survey was sent to program directors of 498 social work schools to explore the developmental disabilities content in their curricula. The survey measured developmental disabilities content in terms of course content, practice opportunities, research opportunities, and value content. The response rate was 28.9%. Results indicated that very few schools offered developmental disabilities content in their curricula, and those that did offered it primarily as a field practica experience. Survey findings raise concerns about how well social work students are being prepared for practice in the field of developmental disabilities.

Bacteriochlorophyll organization and energy transfer kinetics in chlorosomes from Chloroflexus aurantiacus depend on the light regime during growth

We have used measurements of fluorescence and circular dichroism (CD) to compare chlorosome-membrane preparations derived from the green filamentous bacterium Chloroflexus aurantiacus grown in continuous culture at two different light-intensities. The cells grown under low light (6 μmol m(-2) s(-1)) had a higher ratio of bacteriochlorophyll (BChl) c to BChl a than cells grown at a tenfold higher light intensity; the high-light-grown cells had much more carotenoid per bacteriochlorophyll.The anisotropy of the QY band of BChl c was calculated from steady-state fluorescence excitation and emission spectra with polarized light. The results showed that the BChl c in the chlorosomes derived from cells grown under high light has a higher structural order than BChl c in chlorosomes from low-light-grown cells. In the central part of the BChl c fluorescence emission band, the average angles between the transition dipole moments for BChl c molecules and the symmetry axis of the chlorosome rod element were estimated as 25° and 17° in chlorosomes obtained from the low- and high-light-grown cells, respectively.This difference in BChl organization was confirmed by the decay associated spectra of the two samples obtained using picosecond single-photon-counting experiments and global analysis of the fluorescence decays. The shortest decay component obtained, which probably represents energy-transfer from the chlorosome bacteriochlorophylls to the BChl a in the baseplate, was 15 ps in the chlorosomes from high-light-grown cell but only 7 ps in the preparation from low-light grown cells. The CD spectra of the two preparations were very different: chlorosomes from low-light-grown cells had a type II spectrum, while those from high-light-grown cells was of type I (Griebenow et al. (1991) Biochim Biophys Acta 1058: 194-202). The different shapes of the CD spectra confirm the existence of a qualitatively different organization of the BChl c in the two types of chlorosome.

Gastric toxoplasmosis in acquired immunodeficiency syndrome: antemortem diagnosis with histopathologic characterization

Gastrointestinal symptoms attributable to Toxoplasma gondii infection are distinctly unusual, and antemortem diagnosis of gastrointestinal involvement is rarely documented, particularly in the absence of cerebral manifestations or disseminated disease. This case report describes a rare example of T. gondii infection of the stomach diagnosed antemortem in a 22-year-old Haitian woman with acquired immunodeficiency syndrome (AIDS) who presented with fever and abdominal pain. An abdominal computerized tomographic scan showed thickened gastric walls. Endoscopy showed diffusely thickened gastric folds and a fundic ulcer along the greater curvature. Light and electron-microscopic examination of gastric mucosal biopsy specimens showed active Toxoplasma infection with necrosis and intracellular trophozoites within the gastric epithelium, smooth muscle cells, macrophages, and endothelial cells. Both true cysts and pseudocysts were seen. Disseminated disease was documented by the growth of T. gondii in a tissue culture from a venous blood sample. It is concluded that some patients with AIDS, particularly those from areas endemic for Toxoplasma infection, can manifest disseminated disease in unusual locations such as the gastrointestinal tract. Documentation of active T. gondii infection based on tissue cultures of venous blood or on biopsy specimens of symptomatic extracerebral sites can lead to a rapid diagnosis of toxoplasmosis, a treatable disease.

Angiotensin converting enzyme gene I/D polymorphism, blood pressure and the renin-angiotensin system in Caucasian and Afro-Caribbean peoples

The objectives of this study were to assess relations between ACE gene I/D polymorphism, essential hypertension, plasma renin activity and aldosterone in white (European descent) and black (Afro-Caribbean descent) peoples. Measurements were carried out on a total of 320 subjects (210 white: 116 men, 94 women; 110 black: 65 men, 45 women); all were on their usual sodium intake; none was on anti-hypertensive therapy and none had secondary hypertension. Genomic DNA was isolated from blood cells and ACE I/D genotype was established using polymerase chain reaction. Plasma hormones were measured by radioimmunoassay and blood pressure (BP) with an ultrasound sphygmomanometer. All subjects were grouped into normotensive, borderline and hypertensive according to WHO guidelines. The distribution of the I/D genotype in the white people was approximately 1:2:1; by contrast, in the Afro-Caribbean people there was a significantly higher frequency of the D allele (chi 2P = 0.04). Within the white people there was no significant association between ACE genotype and high BP; however, within the black people there was a positive association between the frequency of the D allele and increasing BP ( chi 2 for trend P = 0.03). In either group, there were no associations between ACE I/D genotype and plasma renin activity and aldosterone suggesting that ACE genotype does not contribute to the expression of the circulating renin-angiotensin system. This study highlights differences in ACE I/D polymorphism between white and black peoples and suggests the possibility of racial differences in the association between ACE genotype and BP.

Endocrine disorders: new technology allows quick, accurate diagnosis

In the past 50 years, the development of radio-immunoassay and other precise diagnostic tools has led to elucidation of the pathophysiology of many endocrine disorders. This in turn has enabled clinicians to make quick, accurate diagnoses of diseases that increase in frequency with advancing age, such as thyroid disorders, diabetes, osteoporosis, and hyperparathyroidism. Specific, effective therapies such as the oral sulfonylureas for diabetes and both hormonal and nonhormonal treatments for osteoporosis have improved the longevity and quality of life of older individuals with these diseases. Newer tests give us the ability to closely monitor therapeutic effectiveness.

Cause of temporary closure of an inner-city trauma center

The number of trauma admissions, types of injury, and reasons for temporary closure were studied. Trauma patients admitted numbered 1120 in 1991, 989 in 1992, and 1164 in 1993; blunt trauma accounted for 77 percent, 74 percent, and 80 percent, whereas penetrating trauma accounted for 23 percent, 26 percent, and 20 percent of the admissions by year, respectively. A mean of 81 percent of the blunt trauma studies were for head injuries. The trauma center closed for a total of 260 hours in 1991, 211 hours in 1992, and 240 hours during 1993. Of the total hours closed, the unavailability of computed tomography (CT) scanning due to mechanical reasons was the leading cause for closure, accounting for 59 percent of hours closed. Other reasons for closure included operating (OR) unavailability (33%), acute care beds full (3.4%), blood bank stock shortage (1.4%), insufficient OR nursing teams (0.6%), unavailability of anesthesiologists (0.5%), unavailability of surgical team (1.4%), and hospital water problems (1.4%). It is concluded that designated major trauma centers may need two available CT scanners if they have a greater than 75 percent blunt trauma admission rate, or greater than 500 blunt trauma patient admissions.

Hyponatremia in a nursing home population

OBJECTIVE

To determine the prevalence of hyponatremia in a nursing home population and to identify clinical factors that increase the risk for development of hyponatremia.

DESIGN

Retrospective and prospective record review.

SETTING

A Veterans Affairs nursing home care unit.

PATIENTS

One hundred nineteen residents, who ranged in age from 60 to 103 years. Sixty ambulatory patients, 62 to 91 years of age, who attended a geriatric medicine outpatient clinic served as a reference population.

MEASUREMENTS

Most recent serum sodium, creatinine, BUN, and all serum sodium determinations during the preceding 12 months; clinical diagnoses, diet, medications, and significant events at the time of recorded hyponatremic episodes; response to acute water loading in a subset of patients; number of deaths in the 12 months following entry into the study.

RESULTS

In the 119 nursing home patients, ages 60 years or older, the most recent serum sodium identified 18% who were hyponatremic, compared with a prevalence of 8% in similarly aged ambulatory patients. When all serum sodium determinations for the previous 12 months were examined, 53% of the nursing home patients had at least one episode of hyponatremia during this time period. There was a high incidence of central nervous system (CNS) and spinal cord disease in the total nursing home population. Episodes of hyponatremia were frequently associated with an increased intake of fluids, given either orally or intravenously, and with tube feeding. Water load testing revealed abnormal water handling consistent with the syndrome of inappropriate antidiuretic hormone (ADH) secretion in 18 of 23 patients who had a history of hyponatremia. Seventeen percent of the patients with hyponatremia died over the following 12 months, compared to a death rate of 21% in the normonatremic patients.

CONCLUSIONS

Hyponatremia is a common occurrence in nursing home residents and may be a consequence of abnormal ADH secretion resulting from CNS disease. Exposure to increased fluid intake, or to a low sodium tube-feeding diet, can lead to the onset of hyponatremia or to a worsening of an already present low-serum sodium concentration.

Breastfeeding difficulties as a result of tight lingual and labial frena: a case report

A breastfed baby with impending failure to thrive resisted assuming a wide-mouthed, flanged-lip position at breast. A lingual frenotomy was only partly successful in correcting his breastfeeding problems. Following a labial frenectomy, the baby was better able to flange his upper lip against the breast. He then began breastfeeding with full efficiency.

A prospective, randomized trial of phenytoin in nonepileptic subjects with reduced HDL cholesterol

Observational studies have demonstrated a positive association between phenytoin use and HDL cholesterol (HDL-C). Our goal was to determine whether phenytoin raises HDL-C in nonepileptic subjects at risk for coronary artery disease. We performed a double-blind, placebo-controlled, parallel-group study in 41 subjects with reduced levels of HDL-C. Subjects were placed on an American Heart Association Step I diet and were randomized to receive either phenytoin or placebo for 3 months. Serum levels of phenytoin were monitored and adjusted to between 7.5 and 15 micrograms/mL. Fasting levels of lipids and lipoproteins were determined twice at baseline (weeks -2 and -1) and during the treatment phase of the study (weeks 11 and 12). Compared with dietary baseline, phenytoin-treated subjects experienced significant paired percent increases in total HDL-C (12.4%; P < .01), an effect confined to the HDL2 subfraction (137%; P < .01). The paired percent increases in HDL-C and HDL2 levels remained significant after adjustment for placebo (P < .05, P < .025, respectively). There were no significant differences in the paired percent changes from dietary baseline in total cholesterol, triglyceride, or LDL cholesterol levels between placebo and phenytoin-treated groups. The significant paired percent increases in total HDL-C and HDL2 from dietary baseline suggest a potential role for phenytoin in subjects with reduced levels of HDL-C.

Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss

Certain symptoms of grief have been shown (a) to be distinct from bereavement-related depression and anxiety, and (b) to predict long-term functional impairments. We termed these symptoms of "complicated grief" and developed the Inventory of Complicated Grief (ICG) to assess them. Data were derived from 97 conjugally bereaved elders who completed the ICG, along with other self-report scales measuring grief, depression, and background characteristics. Exploratory factor analyses indicated that the ICG measured a single underlying construct of complicated grief. High internal consistency and test-retest reliabilities were evidence of the ICG's reliability. The ICG total score's association with severity of depressive symptoms and a general measure of grief suggested a valid, yet distinct, assessment of emotional distress. Respondents with ICG scores > 25 were significantly more impaired in social, general, mental, and physical health functioning and in bodily pain than those with ICG scores < or = 25. Thus, the ICG, a scale with demonstrated internal consistency, and convergent and criterion validity, provides an easily administered assessment for symptoms of complicated grief.

The asymmetry of P+ in bacterial reaction centers revealed by circular dichroism spectroscopy

The circular dichroism anisotropy, (AL-AR)/A, has been measured for the far-red absorption band of P+ in reaction centers of two purple bacteria (Rhodopseudomonas viridis and Rhodobacter sphaerides) and one green sulfur bacterium (Chlorobium tepidum). The anisotropy values for P960+ (Rps. virdis) at 1310 nm was found to be +(13 +/- 2) x 10(-4). The corresponding for P870+ (Rb. sphaeroides) at 1250 nm was +(11 +/- 1) x 10(-4), but for P840+ (C. tepdium) at 1160 nm the value was negative: -(27 +/- 2) x 10(-4). These results show that the configuration of the special pair in P840 is significantly different from the configuration in P870 and P960.

Therapeutic principles and options in radiation oncology

Radiation therapy is used increasingly as a definitive or adjunctive treatment for cancer. Definitive irradiation allows functional preservation of structures critical to function. Adjunctive irradiation following surgical resection of the primary lesion treats regional lymph nodes and/or sites of primary extension at high risk for microscopic involvement. Specialized techniques can be applied to deliver higher total doses of irradiation and minimize late normal tissue effects to adjacent normal tissues. Local-regional tumor control combined with functional preservation represents the specific goals of radiation therapy applied alone or in conjunction with surgical resection.

Monocyte adherence to the subendothelial basement membrane increases interleukin-8 gene expression and antigen release

The emigration of peripheral blood monocytes into the interstitium allows for contact with a variety of surfaces which may provide signals important for monocyte function in both normal and inflammatory states. In the present study, we examined the effect of adherence to an endothelial cell-derived basement membrane and to collagen I, the major collagen of the interstitium, on monocyte release and gene expression of the potent chemotactic cytokine Interleukin-8 (IL-8). We further evaluated neutrophil chemotactic activity of the conditioned media containing antigenic IL-8 from monocytes adherent to these same surfaces. Elutriation-purified monocytes were adhered for 1 hour to plastic tissue culture wells either uncoated (PL) or coated with bovine serum albumin (BSA), collagen type I (C-I), or endothelial cell-derived basement membrane (BM). Following removal of nonadherent cells, monocytes were further incubated in a serum-free media for 18 hours in the presence or absence of lipopolysaccharide (IPS). Following 18 hrs of incubation there were significantly less monocytes remaining adherent to BM when compared to other surfaces tested. In the absence of LPS, adherent monocytes released significant amounts of IL-8 that was not surface specific. In the presence of LPS, monocytes adherent to BM released significantly more IL-8, when corrected for adherent cell number, than monocytes adherent to PL, BSA, or C-I. Conditioned media from adherent monocytes expressed IL-8 dependent neutrophil chemotactic activity that was not influenced by the surfaces tested. Northern blot analysis indicated greater induction for IL-8 mRNA by monocytes adhered to BM after 18 hrs in the presence of LPS. These results suggest that monocyte adherence to the subendothelial basement membrane provides a priming signal for the induction and secretion of the chemotactic cytokine IL-8 in response to inflammatory stimuli.

Australian healthcare: a smart card for a clever country

In this paper we give an overview of smart card technology how a smart card could be used as a healthcare card and the benefits that would most likely result from doing so. The smart card memory can be zoned into different security levels. The top security zone may contain an individual's full medical history while the lowest security zone may contain the cardholders name and address. Access to the different zones depends on the level of security of the zone. The higher the security level the more restrictive the access method. Were smart cards adopted for the storage of medical histories it would change the form of medical information recorded, not merely convert paper files to electronic ones. Storage of an individual's medical history on a smart card raises important privacy issues. These privacy issues are discussed particularly as they relate to the Australian community.

The clinical effects of intensive, specific exercise on chronic low back pain: a controlled study of 895 consecutive patients with 1-year follow up

Eight hundred ninety-five consecutive chronic low back pain patients were evaluated. Six hundred twenty-seven completed the program. One hundred sixty-one began, but dropped out, and 107 were recommended for treatment but did not undergo treatment for various reasons. Average duration of symptoms prior to evaluation was 26 months. Forty-seven percent of patients were workers' compensation patients. The primary treatment was intensive, specific exercise using firm pelvic stabilization to isolate and rehabilitate the lumbar spine musculature. Patients were encouraged to work hard to achieve specific goals. Seventy-six percent of patients completing the program had excellent or good results. At 1-year follow up 94% of patients with good or excellent results reported maintaining their improvement. Results in the control group were significantly poorer in all areas surveyed except employment.