"H" reflex as a measure of subclinical uremic polyneuropathy in children with chronic renal failure

Uremic polyneuropathy (UPNP) is a serious complication of chronic renal failure (CRF) in adults; however, its prevalence is unknown in the pediatric population. An easy-to-perform maneuver for its detection in children is the evaluation of "H" reflex. The objective of this study was to validate the usefulness of the "H" reflex maneuver for the diagnosis of UPNP in pediatric dialysis patients for CRF. Thirty-seven CRF patients were paired with healthy controls by age and sex. The patients were being treated with dialysis or one of its variants. Information was obtained regarding diagnosis, duration, and control of dialysis. Neurological examination was performed, conduction velocities in sensory and motor nerves were measured, and "H" reflex elicited bilaterally. Peripheral polyneuropathy was determined by the presence of at least two nerves with alterations in latency and/or conduction velocities. It was found that 59.4% (22/37) of the children with CRF treated with dialysis developed UPNP, 17 with ambulatory peritoneal dialysis, and 5 with hemodialysis. There was no difference in diagnosis, duration of dialysis, or control of the same in these patients from other CRF patients who did not have UPNP. All patients were clinically asymptomatic. "H" reflex showed a sensibility of 44%, a specificity of 87%, a predictive value positive of 66%, and a predictive value negative of 76%, when measured to 28 msec. With a 30 msec duration specificity rises to 95%. UPNP presents asymptomatically in pediatric patients. "H" reflex is an adequate screening test for the selection of pediatric patients to be tested further.

Sustained response to interferon in a patient with common variable immunodeficiency and hepatitis C

Hepatitis C infection progresses faster in patients with hypogammaglobulinemia, often leading to death from liver failure within 10 yr of exposure. Response to interferon treatment has been poor in these patients. We report the case of a patient with common variable immunodeficiency and hepatitis C in whom a sustained biochemical and viral remission was obtained after treatment with interferon.

Preoperative autologous blood donations before elective hysterectomy

OBJECTIVE

To determine whether preoperative autologous blood donation is justified for patients undergoing elective abdominal or vaginal hysterectomy.

DESIGN

Retrospective cohort study.

PATIENTS AND SETTING

A total of 263 consecutive patients admitted for elective abdominal or vaginal hysterectomy to a community health maintenance organization hospital during 1993 and 1994.

MAIN OUTCOME MEASURES

Evaluation of transfusion rates for patients who did and did not donate autologous blood; determination of any risk factors that would predict the need for transfusion; and evaluation of the need for transfusion based on chart review.

RESULTS

Of 263 patients, 26 received a blood transfusion. The major risk factor identified for transfusion was the donation of autologous blood. Of 140 patients who donated autologous blood, 25 were transfused, whereas just 1 patient of 123 who did not donate autologous blood was transfused (P<.001). Patients who donated autologous blood had significantly lower mean admission hemoglobin level than patients who did not donate (119 g/L vs 132 g/L; P<.05); logistic regression showed that autologous donation was an independent risk factor for transfusion.

CONCLUSION

For hysterectomy patients, donation of autologous blood causes anemia and is associated with a more liberal transfusion policy. These 2 factors result in a markedly increased incidence of transfusion with its associated risks. Elimination of preoperative autologous donation for these patients should not result in frequent exposure to allogeneic blood.

Prevention of recurrent esophageal bleeding and survival in patients with alcoholic cirrhosis: a randomized study

OBJECTIVES

To compare endoscopic sclerotherapy, propranolol and distal splenorenal shunt in the prevention of rebleeding esophageal varices and mortality in alcoholic cirrhotics.

METHODS

Forty-three alcoholic cirrhotics that had bled from esophageal varices were randomized to sclerotherapy (13), shunt (15) or propranolol(15). Outcomes measured were rebleeding from varices and death.

RESULTS

There was no significant difference between the three treatment groups in relation to rebleeding rate or death. Continued alcohol consumption did not influence outcome.

CONCLUSIONS

All three therapies were equally effective in preventing rebleeding from varices.

Cost of implanting a cemented versus cementless femoral stem

Fifty stratified unselected cases of primary uncomplicated total hip arthroplasty performed at the total joint service of a university teaching hospital were examined. In 25 cases, the femoral stem was implanted with cement, and in the other 25, a cementless stem was implanted. For cemented stems, third-generation cement technique was used, including centrifugation. The average cost to the hospital for a cementless stem was $900 greater than for a cemented stem. The total cost to the hospital for accessories used to achieve modern cement technique was over $700. The operative time for implanting a cemented stem averaged 20 minutes longer, which resulted in an additional operating time charge of $270 and an additional anesthesia charge of $100. When these charges are added to the cost of cement and accessories, the actual cost to the hospital for implanting a modern cemented stem was greater than for a corresponding cementless stem.

Sequential test selection in the analysis of abdominal pain

Numerous decision-making tools exist to assist physicians in diagnosis management. However, the accuracy of available clinical information is often ambiguous or unknown and current analytical models do not explicitly incorporate judgementally defined information. A model encompassing both physician judgment and probability analysis was developed to accommodate such data. A problem requiring sequential diagnostic testing was structured utilizing the analytic hierarchy process (AHP). The case presented involved a patient complaining of upper abdominal pain who, after initial evaluation, did not need immediate surgery. Physicians were faced with identifying the optimal sequence of diagnostic testing. The criteria used for test selection included minimizing risk, patient discomfort, and cost of testing and maximizing diagnostic capability. Although at the onset the "best" test choice was unknown, the clinical picture indicated four test alternatives: upper gastrointestinal series (GI), abdominal ultrasonography (US), abdominal computed tomography (CT), and upper gastrointestinal endoscopy (END). Based upon the relative preferences of the criteria utilized, the AHP analysis indicated that upper GI series was the optimal first test. Given a negative test, posterior probabilities were calculated using Bayes' theorem, resulting in a new estimate of diagnostic capability. The AHP analysis was reiterated, identifying abdominal ultrasonography as the optimal second test. This analysis may be repeated as many times as necessary. Sensitivity analysis demonstrated that changing criteria preferences may alter the choice of tests and/or their sequence.

Quality assurance in anatomic pathology: automated SNOMED coding

This case study details the set-up and implementation of the PathNet autocoder (Cerner Corporation) in a busy anatomic pathology laboratory. After initial start-up, procedures were developed to improve the system's performance. Four classes of software coding errors were identified, and an index was developed to measure the number of cases between errors (CBE). Through modifications in the program, the CBE increased sharply by the end of the six-month study period. During the last three months of the study, the efficiency of case retrieval was tested by comparing manual and electronic methods on the same reference cases. This demonstrated significant time saving and removed the variability of manual coding. The technique employed in this study may assist other institutions seeking to implement such a coding system within their respective environments.

Xanthogranulomatous pyelonephritis associated with transitional cell carcinoma of the renal pelvis

Xanthogranulomatous pyelonephritis (XPN) is an uncommon, but not rare, type of bacterial infection of the kidneys. Malignancies originating within the renal pelvis are uncommon. We report a case of XPN associated with a transitional cell carcinoma (TCC) of the renal pelvis in a 70-year-old woman. The pathogenesis of carcinoma of the renal pelvis in the presence of XPN is related to obstruction, chronic inflammation, and mechanical irritation caused by calculi. In the case reported here, obstruction was due to a concomitant TCC of the ureter without the presence of calculi. A review of the twelve published case reports of XPN with TCC of the renal pelvis, including the present case, showed that the frequency of this association is 3.3%, the average age at presentation is 65.3 (range 49-78) years, and that the male:female ratio is 2:1. Moreover, 25% of the patients had TCC of the ureter and 8.3% TCC of the bladder. The combination of XPN, TCC of the renal pelvis, and lithiasis occurred in 33.3% of the cases. XPN must be treated by nephrectomy not only because it is a destructive inflammatory process leading to complete loss of renal function, but also because the kidney may be harboring a malignant tumor.

Design of a dual-effect lens on lanthanum-modified lead zirconate titanate for continuous variation of focal length

The design of a Fresnel lens with continuous focal length is proposed for use in optical processing. A convex lens is induced in lanthanum-modified lead zirconate titanate through the application of an electric-field profile supplied by the indium tin oxide electrodes that make up the zones of a Fresnel lens. The use of a numerical method based on fast Fourier transform algorithms was required to analyze accurately the induced field inside a Fresnel lens with an initial focal length of 0.4 m (at 470 nm) and 20 indium tin oxide electrodes. The effective focal location obtained by the combined mechanisms is derived. This design is expected to produce continuous variations of ~16% in focal length; the ability of previous designs to achieve focal length switching is maintained.

[Research on prognostic factors in large-cell lymphomas]

BACKGROUND

To carry out a study on the prognostic factors in large cell lymphomas (LCL) treated during the last decade and validate the international prognostic index (IPI).

METHODS

One hundred twenty-four cases of newly diagnosed LCL, treated from 1978 to 1990, with a mean follow up of 27 months (1-142) were included in the study. The chemotherapy used was: CHOP (65%), ProMACE-CytaBOM (17%) and others (C-MOPP, MACOP-B).

RESULTS

Complete remission (CR) was achieved in 71% of the cases and partial in 11%. Logistic analysis allowed the identification of three adverse factors to CR: Ann Arbor stage III, IV (p = 0.004; odds ratio, OR = 0.19), elevated tumoral load (p = 0.006; OR = 0.22) and age > or = 60 years (p = 0.02; OR = 0.31). Recurrence free survival (RFS) at 3 years was 67% (CI 95%; 55-79) with the median not having been achieved. Cox analysis allowed the identification to the ECOG > or = 2 scale as the only independent adverse factor (p = 0.0006; RR = 4.85) while Ann Arbor staging demonstrated marginal influence (p = 0.08). Global survival (GS) at 5 years was 45% (CI 95%; 35-55) with a median of 38 months. Multivariant analysis of independent adverse factors of GS were ECOG scale > or = 2 (p < 0.00001; RR = 6.07), Ann Arbor stage (p = 0.004; RR = 2.64) and hypoalbuminemia (p = 0.01; RR = 2.28). On inclusion of therapeutic response (TR) in the analysis, the factors chosen were absence of CR (p < 0.00001; RR = 9.58) and ECOG > or = 2 (p = 0.0004; RR = 4.24).

CONCLUSIONS

Three variables evaluated at diagnosis, general state (ECOG), Ann Arbor stage and albumin, determined the prognosis in this series of large cell lymphoma. A prognostic model was designed from the same with three risk groups. The application of the international prognostic index to this series separated the patients into 4 groups of differentiated prognosis.

Optimal interval for triple-lumen catheter changes: a decision analysis

A survey of 53 university and community hospitals revealed that 73% of the institutions had no standard policy for the replacement of triple-lumen catheters (TLCs). Since the maintenance of a TLC in place for a prolonged period may lead to infectious complications, it appeared warranted that standards of management be developed. A decision-tree model was constructed for evaluating the optimal time for changing a TLC that would minimize infection. Cost estimates and health effects at three-, five-, and ten-day change intervals were considered for catheter insertion and complications resulting from such insertion. The results suggested that prophylactic catheter changes should occur no later than every five days, provided that there are no signs of infection. However, sensitivity analysis of several variables suggested that individual institutions should establish policy timing changes based upon careful interpretation of their own data. A model was developed to assist in determining the optimal time to change a TLC based upon such data.

Manganese toxicity: free amino acids in the striatum and olfactory bulb of the mouse

We studied the levels of twenty two free amino acids in the striatum and olfactory bulb of mice treated during nine weeks with daily intraperitoneal injections of manganese chloride at a concentration of 5.0 mg Mn+2/kg body weight. In the olfactory bulb the contents of alanine, alpha-amino-n-butyrate, arginine, asparagine, aspartate, citrulline, GABA, glutamate, glycine, isoleucine, leucine, methionine, phenylalanine, serine, threonine, tyrosine, and valine were diminished. No alterations were observed in the concentrations of free amino acids in the striatum of Mn-treated mice. The changes detected in the olfactory bulb merit a thorough evaluation in order to determine its importance on the pathophysiology of manganese poisoning.

Protrusion of the optic nerve into the ethmoid and sphenoid sinus: prospective study of 150 CT studies

Damage to the optic nerve is a serious complication of intranasal sinus surgery. Protrusion of the optic canal into the sphenoid sinus is a major risk factor. In this prospective study of 150 CT studies, we found this anatomical variation in 8% of cases. It was consistently associated with pneumatisation of the ipsilateral anterior or clinoid process. Protrusion of the optic nerve into the posterior ethmoid cells was never observed. CT is a useful part of the preoperative investigation of patients undergoing intranasal sinus surgery. Axial and coronal images obtained or by direct acquisition by reconstructions are necessary to show the position of the optic nerve.

Schistosomiasis in the Republic of São Tomé and Principe: characterization of Schistosoma intercalatum

This paper reports the morphological and biochemical characterization of the species of Schistosoma infecting humans in the Republic of São Tomé and Principe. The eggs are typical in shape and size of S. intercalatum, measuring on average between 174.5 microns and 189.1 microns. The eggs are voided in the faeces and not the urine of infected people. The parasite experimentally develops in several different species of Bulinus belonging to the B. forskalii group, including B. forskalii, with a minimum prepatent period of 25 d, and also in snails of the B. reticulatus group (B. wrighti); it is incompatible with snails of the B. africanus and B. truncatus/B. tropicus complex. A survey of 5 different habitats at intervals of 2 weeks over a period of one year showed that populations of B. forskalii increased during the dry period of June, July and August in 1988, and in 3 of the habitats snails were present throughout the year. Hence transmission may take place in these habitats throughout the year. Preliminary evidence suggests that water velocity is a limiting factor confining Bulinus to the north-east of the island where the terrain is less mountainous. Development of schistosomes from São Tomé was followed in experimentally infected hamsters. The cross-over point (the point at which the paired male and female worms are of the same average length) occurred at about 49 d after infection: eggs were first seen in the uteri of the female worms 48 d after infection. The parasite from São Tomé developed in sheep and produced viable eggs.(ABSTRACT TRUNCATED AT 250 WORDS)

Manganese toxicity: muscarinic receptor binding in the mouse brain

In the present study we determined the effect of repeated administration of manganese chloride on the binding parameters of [3H]quinuclidinyl benzilate (3H-QNB) in striatum, frontal cortex, and hippocampus of mice. Daily intraperitoneal injections of manganese chloride (5 mg Mn/kg) 5 d/wk during 9 wk did not alter the receptor density (Bmax) and the dissociation constant (Kd) of 3H-QNB in the different brain regions studied. These results suggest that chronic treatment with manganese does not affect the binding characteristics of 3H-QNB to the cholinergic muscarinic receptors in mouse brain.

Major complications of sinus surgery: a review of 1192 procedures

Based on this review of 1192 intranasal sinus procedures under endoscopic control with video assistance, the risk of major complications was estimated to be about 1.3 per cent. Ethmoidectomy was the most hazardous procedure. Operation by a right-handed surgeon standing on the right side of the patient was an added risk factor. We stress ways of achieving prevention, peroperative recognition of cerebrospinal fluid leaks and proper management of complications.

Dehiscence of the lamina papyracea of the ethmoid bone: CT findings

PURPOSE

To describe the CT findings characterizing dehiscence of the lamina papyracea.

METHODS

Axial and coronal CT scanning of the paranasal sinuses was performed on 783 patients.

RESULTS

Dehiscence of the lamina papyracea was noted incidentally in six patients. In all cases dehiscence was characterized by protrusion of orbital fat through a gap in the anterior ethmoid. The posterior limit of the dehiscence was always the basal lamella. The anterior limit varied.

CONCLUSION

CT scans are often taken to detect polyps or assess chronic sinusitis. Awareness of dehiscence of the lamina papyracea is important to avoid misdiagnosis as infectious or tumoral process and possible injury of the orbit during endoscopic surgery.

Fibroblast response to metallic debris in vitro. Enzyme induction cell proliferation, and toxicity

Bovine synovial fibroblasts in primary monolayer culture were exposed to particulate metallic debris. The effects of the metallic particles on the synthesis and secretion of proteolytic enzymes and on cell proliferation and viability were examined. Uniform suspensions of titanium, titanium-aluminum, cobalt, and chromium particles, ranging in size from approximately 0.1 to ten micrometers (average, one to three micrometers), were prepared; the particle concentrations (the volume of particles divided by the total volume of the suspension) ranged from 0.0005 to 5 per cent. Aliquots of the particle suspensions were added to the synovial fibroblast cultures. The final particle concentrations in the media ranged from 0.0000083 to 0.83 per cent. After seventy-two hours of exposure, each medium was harvested and was assayed for proteolytic and collagenolytic activity and for hexosaminidase levels. Neutral metalloproteases, quantified by collagenolytic and caseinolytic (proteolytic) activity, represent enzymes, secreted by cells, that are capable of degrading extracellular matrix. Hexosaminidase is a marker for lysosomal enzyme activity that can include more than thirty enzymes, such as proteases, lipases, nucleases, and phosphatases. Cell proliferation was quantified by uptake of 3H-thymidine. Cell morphology was examined by scanning electron microscopy. Titanium, titanium-aluminum, and chromium significantly stimulated 3H-thymidine uptake at low particle concentrations (p < 0.01, p < 0.002, and p < 0.002, respectively). Exposure to cobalt, even at the lowest particle concentration, resulted in a significant decrease in thymidine uptake (p = 0.027). At the highest particle concentrations, all particles were toxic, as evidenced by the absence of thymidine uptake. At high particle concentrations, all of the metals caused a decrease in caseinolytic (proteolytic) and collagenolytic activity in the culture media. Titanium elevated the lysosomal enzyme marker, hexosaminidase, except at high concentrations. Chromium and titanium-aluminum had no significant effect on hexosaminidase at any particle concentration, while cobalt decreased all enzyme markers at mid-particle to high-particle concentrations. Scanning electron microscopy demonstrated that the morphological response of fibroblasts to titanium included membrane-ruffling and extension of filopodia, typical of active fibroblasts. In contrast, exposure to cobalt at the same concentration resulted in cell crenation, indicative of cell death.

[Biomass of Rhizopus oligosporus as an adsorbent for metal ions]

The effect of different parameters on the adsorption of metal ions by Rhizopus oligosporus has been studied. The uranium sorption by dried biomass was rapid, reaching in 5 min around 95.% of the binding capacity. The uranium-binding capacity of the culture showed an inverse relation to the growth kinetic. The relationship between sorption and equilibrium concentration was similar to an adsorption isotherm. Using the Langmuir model, a maximum sorption capacity of 0.52 mmoles uranium/g dry biomass and an affinity constant of 101 l/mmol uranium at pH 4.15 were determined. The best capacity of the biomass to bind ions (UO2(2+), Cu2+, Cd2+ and Zn2+) was best at pH 4.5-5.5. By using hydrochloric acid as eluant a 18% uranium removal of the biomass-bound ions was obtained at pH 1.0. The presence of other cations inhibited uranium-binding in the following order: Cu2+ > Cd2+ > Zn2+ > Mg2+ > Ca2+.

Radiohistology and histochemistry of barium granuloma of the colon and rectum

Barium granuloma of the colon and rectum is a rare complication of X-ray examination of the digestive tract using barium. The authors report 5 new cases occurring in the last 3 years. Histological examination revealed a granulomatous reaction with greyish finely granular refractile PAS-negative material located in the cytoplasm of histiocytes and in the interstitial space. The radiographic study of the paraffin blocks confirmed the nature of this material, which was X-ray opaque, and this was corroborated histochemically with the rhodizonate technique.

Septic endophthalmitis associated with bacteremia and liver abscess caused by Klebsiella pneumoniae

Pyogenic liver abscess is a serious clinical problem associated with severe complications in 10-20% of cases. Metastatic septic endophthalmitis is a rare complication associated with liver abscess. Despite appropriate treatment the outcome is devastating. We will review in this case presentation some important aspects of the etiology, diagnosis and treatment recommendations for septic endophthalmitis.

Identification of correlates of physical activity among Latino adults

127 Latino adults responded to a survey concerning physical activity. Respondents over-represented well educated and middle class Latinos. Subjects reported a mean of 48 minutes/week of walking for exercise. This sample reported less than two episodes per week of vigorous physical activity, again below the recommended 3/wk needed to insure cardiovascular fitness. We expect more representative samples to engage in less physical activity. Stepwise multiple regression analyses were conducted using 24 variables based on Social Learning Theory. A multiple R of 0.66 accounted for over 27% of the variance in walking for exercise (p less than 0.001). Older adults, those with a history of childhood injury, and those who reported friend support were more likely to walk for exercise. Respondents who participated in physical activity during childhood and adolescence (including formal physical education in school) and, paradoxically, those who had models for exercise in childhood were less likely to walk for exercise. A multiple R of 0.75 accounted for 43% of the variance in vigorous physical activity and reached significance (p less than 0.001). Self-efficacy, friends' support, childhood physical activity, and eating a heart healthy diet were positively related to vigorous activity. These results suggest that different correlates influence walking versus vigorous activity, and that correlates of physical activity are different for Latinos compared to Anglos. The findings emphasize the need for larger scale investigations of the determinants of activity within the Latino population.