Renal replacement therapy after repair of congenital heart disease in children. A comparison of hemofiltration and peritoneal dialysis

The development of renal failure necessitating peritoneal dialysis after cardiac operations is associated with a reported mortality greater than 50%. Improved fluid removal and nutritional support have been reported with the use of continuous arteriovenous hemofiltration and continuous venovenous hemofiltration techniques. We have compared our experience with all three techniques in managing children who required renal replacement therapy after cardiac operations in terms of efficacy (fluid removal, calorie intake, and clearance of urea and creatinine), complications, and outcome. Over a 5-year period renal replacement therapy was initiated in 42 children, and in 34 of them it was successfully established for more than a 24-hour period: 17 were managed with peritoneal dialysis, 8 with continuous arteriovenous hemofiltration, and 9 with continuous venovenous hemofiltration. A net negative fluid balance was achieved in only 6 (35%) patients treated with peritoneal dialysis compared with 50% of those treated with continuous venovenous hemofiltration and 89% of those treated with continuous venovenous hemofiltration. In terms of nutritional support, calorie intake increased by 43% after peritoneal dialysis was started compared with 515% and 409% in the arteriovenous and venovenous hemofiltration groups, respectively, (p < 0.005). The serum urea levels fell by 36% (p = 0.02) and 39% (p = 0.005) compared with pre-therapy levels with arteriovenous and venovenous hemofiltration, respectively, and the creatinine content was reduced by 19% and 33% (p = 0.003). Neither parameter was reduced in the peritoneal dialysis group. We conclude that the use of hemofiltration as a renal replacement therapy after surgical correction of congenital heart disease offers significant advantages over the more traditional approach of peritoneal dialysis. In addition, we suggest that a more aggressive approach to the management of fluid overload and nutritional depletion with hemofiltration may result in a decrease in the very high mortality seen in renal failure after cardiac operations.

A treatment system for combined psychiatric and addictive illness

Patients with combined general psychiatric and addictive disorders are a major public health problem in the US, and are being increasingly recognized as such world-wide. The authors describe a model treatment system for such patients in one municipal hospital in New York. It is composed of three complementary units: a locked ward, a halfway house and a day program. Treatment is based on a peer leadership approach coupled with professional treatment, and provides multiple levels of care to address the needs of respective patients. Of 464 admissions evaluated and treated, most were from disadvantaged minorities, homeless and abusers of cocaine. All were admitted with acute psychiatric or perinatal presentations, and carried Axis I diagnoses in addition to their substance abuse. Clinical experience over 6 years is reviewed, suggesting the feasibility of reorganizing general hospital psychiatric services to address the needs of the dually diagnosed.

Antiandrogen action in the development of androgen insensitivity in S115 mouse mammary tumour cells

Endocrine therapy for steroid-sensitive tumours often involves administration of steroid antagonists which are designed to bind to the steroid receptor and block steroid action. However, the clinical problem remains the temporary nature of the tumour regression. Since in vitro models suggest that steroid ablation itself can result in loss of steroid sensitivity of tumour cells, these studies aimed to investigate the influence of the antiandrogen ICI 141,307 on this progression. This antiandrogen exhibits both agonist and antagonist actions on androgen-regulated cellular and molecular parameters of S115 mouse mammary tumour cells in culture. Its ability to regulate mouse mammary tumour virus (MMTV) RNA production in these cells confirms that the antiandrogen-receptor complex can not only bind to the steroid response element (SRE) in the MMTV DNA sequences but also activate gene transcription. Despite these molecular abilities of this antiandrogen, it was still unable to maintain androgen sensitivity in the long term. It was able to delay progression to insensitivity of the various steroid-regulated parameters, although the different parameters were delayed for different lengths of time, but ultimately the antiandrogen was unable to prevent loss of any parameters. It is thus concluded that the nature of the ligand is critical for maintenance of steroid sensitivity: only androgen and not antiandrogen will maintain long-term response. Previous molecular models for loss of steroid response suggest that it could result from inactivation of SRE in the genome when no receptor complex is bound. However, loss of response occurred in these experiments even in the presence of an activated receptor complex capable of binding to the SRE. Possible molecular mechanisms and the clinical implications are discussed.

Effect of attitudes, subjective norms and perceived control on nurses' intention to assess patients' pain

This study examines the underlying determinants of nurses' behaviour regarding the conduct of pain assessments. One hundred nurses in a variety of health care facilities were invited to complete an Attitude Intention Questionnaire based upon the theory of planned action which is an extension of the theory of reasoned action. Results provide some support for the theory of planned action, as nurses' intention to conduct pain assessment was shown to be predicted by attitude, subjective norms and perceived control, although the latter was the only variable to make an independent contribution to intention. Additional support for the importance of perceived control was provided by the analysis of 'intenders' and 'non-intenders' (to conduct pain assessments), as perceived control was the only variable which differed significantly between the groups. The findings are consistent with earlier studies which showed that the variables in the theory of planned behaviour provided reasonably accurate predictions of behavioural intention.

Rational recovery: alternative to AA for addiction?

Rational Recovery (RR) is a new self-help movement for substance abusers, with a cognitive orientation. It has been suggested as an alternative to Alcoholics Anonymous. This study was designed to examine the nature of RR and its impact on those who join. A national sample of 433 substance-abusing people attending 63 established RR groups was evaluated, using codable self-report questionnaires completed at RR meetings. Members were mostly men with college experience who had previously attended AA. Among recruits who attended their first RR meeting in the last month, 38% were abstinent in the last month. Among members who had joined 3 or more months before, 73% were abstinent in the last month; they had attended an average of 4.1 RR meetings in that month, and carried out exercises at home based on Rational Emotive Therapy. Among those who joined 6 or more months before, 58% reported at least 6 months of abstinence. Among members with a history of heavy cocaine use, the portion reporting abstinence in the last month was not significantly different from those who had never used cocaine. The minority of members who were engaged for 3 months were still drinking, though, and did so on an average of 9.9 days in the last month. RR succeeded in engaging substance abusers and promoting abstinence among many of them while presenting a cognitive orientation that is different from the spiritual one of AA. Its utility in substance abuse treatment warrants further assessment.

Continuous arteriovenous hemofiltration after cardiac operations in infants and children

Acute renal insufficiency after cardiopulmonary bypass can lead to a significant morbidity from fluid overload and electrolyte disturbance, impede pulmonary gas exchange, and postpone weaning from mechanical ventilation. The limitations placed on free water intake result in severe restriction of nutrition while diuretic therapy causes electrolyte imbalance. Artificial renal support either in the form of peritoneal dialysis or hemodialysis may be complicated by sepsis and hemodynamic instability. We reviewed our experience with the use of continuous arteriovenous hemofiltration, an extracorporeal technique for removal of solutes, toxins, and water in critically ill patients with cardiac failure complicated by acute renal insufficiency and hemodynamic instability after cardiopulmonary bypass. Ten infants and children with renal insufficiency caused by low cardiac output had continuous arteriovenous hemofiltration instituted for indications including sepsis, volume overload, oliguria for more than 24 hours nonresponsive to diuretic therapy, and the need for hyperalimentation. All were supported by mechanical ventilation and receiving high-dose inotropic support. Arterial and venous vascular access was successfully obtained by cannulation of the femoral artery and vein in nine patients. Anticoagulation of the circuit was achieved with heparin infusion (6 to 20 micrograms/kg/hr) and monitored by measurement of activated clotting time. The continuous arteriovenous hemofiltration circuit was replaced if there was clot formation, or at 3 days after placement. Dialysis solution (Dianeal) 1.5% or 0.5% was infused as prefilter dilution. With the use of continuous arteriovenous hemofiltration, 20 to 100 m/hr of ultrafiltrate was removed, which allowed correction of hypervolemia, and caloric intake increased from 13.5 kcal/kg/day to 79.5 kcal/kg/day. Continuous arteriovenous hemofiltration was maintained between 5 hours and 8 days and was well tolerated in all patients. Serum urea and creatinine levels declined during continuous arteriovenous hemofiltration. We conclude that continuous arteriovenous hemofiltration is a safe and effective method for fluid and electrolyte homeostasis and that it thus allows hyperalimentation in infants and children after cardiac operations.

A single base pair dominates over the novel identity of an Escherichia coli tyrosine tRNA in Saccharomyces cerevisiae

The Escherichia coli su+3 tyrosine tRNA was shown recently to be a leucine-specific tRNA in Saccharomyces cerevisiae. This finding raises the possibility that some determinants for tRNA identity in E. coli may be different in S. cerevisiae. To investigate whether the fungal system is sensitive to the major determinant for alanine acceptance in E. coli, a single G3 . U70 base pair was introduced into the acceptor helix of the su+3 tyrosine tRNA. This substitution converts the identity of the E. coli suppressor in S. cerevisiae from leucine to alanine. Thus, as in E. coli, G3 . U70 is a strong determinant for alanine acceptance that can dominate over other features in a tRNA that might be recognized by alternative charging enzymes.

A bacterial amber suppressor in Saccharomyces cerevisiae is selectively recognized by a bacterial aminoacyl-tRNA synthetase

Little is known about the conservation of determinants for the identities of tRNAs between organisms. We showed previously that Escherichia coli tyrosine tRNA synthetase can charge the Saccharomyces cerevisiae mitochondrial tyrosine tRNA in vivo, even though there are substantial sequence differences between the yeast mitochondrial and bacterial tRNAs. The S. cerevisiae cytoplasmic tyrosine tRNA differs in sequence from both its yeast mitochondrial and E. coli counterparts. To test whether the yeast cytoplasmic tyrosyl-tRNA synthetase recognizes the E. coli tRNA, we expressed various amounts of an E. coli tyrosine tRNA amber suppressor in S. cerevisiae. The bacterial tRNA did not suppress any of three yeast amber alleles, suggesting that the yeast enzymes retain high specificity in vivo for their homologous tRNAs. Moreover, the nucleotides in the sequence of the E. coli suppressor that are not shared with the yeast cytoplasmic tyrosine tRNA do not create determinants which are efficiently recognized by other yeast charging enzymes. Therefore, at least some of the determinants that influence in vivo recognition of the tyrosine tRNA are specific to the cell compartment and organism. In contrast, expression of the cognate bacterial tyrosyl-tRNA synthetase together with the bacterial suppressor tRNA led to suppression of all three amber alleles. The bacterial enzyme recognized its substrate in vivo, even when the amount of bacterial tRNA was less than about 0.05% of that of the total cytoplasmic tRNA.

Haptic identification of letters using the left or right hand

The present study investigated the effects of the use of the right and left hands on haptic identification of letters of the alphabet. Each of the 64 right-handed subjects was given three series of randomly ordered presentations of the 26 letters of the alphabet. The subjects were asked to feel each letter and name correctly each letter as quickly but as accurately as possible. Analysis showed faster identification by those subjects using their left hands on Series 1 with no hand-differences appearing on Series 2 and 3. Significant over-all improvement in identification time occurred with practice. The results were interpreted in terms of a novelty hypothesis of right-hemisphere function and an explanation of perceptual learning of letter identification.

An E. coli aminoacyl-tRNA synthetase can substitute for yeast mitochondrial enzyme function in vivo

We have investigated the function of an E. coli aminoacyl-tRNA synthetase in S. cerevisiae strains that are respiration-deficient because of a mutation or a gene disruption in the nuclear encoded gene for the mitochondrial tyrosyl-tRNA synthetase. Although the yeast mitochondrial and E. coli tyrosine tRNAs differ significantly in sequence, expression of the E. coli tyrosyl-tRNA synthetase from a gene fusion restores respiration. The fusion gene contains a presumptive sequence for mitochondrial import from the mitochondrial tyrosyl-tRNA synthetase gene fused to the E. coli coding region. The fusion protein is incorporated into mitochondria. This incorporation and the rescue of the respiratory defect require the presumptive sequence for mitochondrial import. These experiments suggest a more limited definition of the identity of a tyrosine tRNA.

New assignment of the adenosine deaminase gene locus to chromosome 20q13 X 11 by study of a patient with interstitial deletion 20q

A karyotype 46,XY,del(20)(q11 X 23q13 X 11) was found in a three year old boy with mental and growth retardation, low set ears, broad nasal bridge, and macrostomia. Adenosine deaminase (ADA) activity was reduced by about 50%, assigning the gene locus to the deleted segment. A review of the previously reported regional assignments suggests that the ADA gene is in the region of band 20q13 X 11.

Dental caries prevalence in children with a diet free of refined sugar

A study of the caries and dental hygiene status of 73 children living in the Synanon community revealed a mean DMF-S score at 0.53 for the 5-10 year old group and 3.33 for the 11-17 year old group. In spite of poor oral hygiene, 53 per cent of the children were caries-free and none of the children was missing permanent teeth. The children had consumed a diet free of refined carbohydrates for five years and had received optimal fluoride supplementation since birth or joining Synanon.

Thymectomy for myasthenia gravis

Thymectomy was performed on 249 patients with myasthenia gravis between 1957 and 1981. During a follow-up period that ranged from 2 months to 24 years (mean 7.5 years), the remission rate for the entire group was 51 percent, and an additional 36 percent had improvement (87 percent benefited). In those 51 patients with thymoma, the remission rate was 37 percent, with 68 percent of the patients benefiting from operations. The remaining 198 patients fared better after the operation: 54 percent had remission and a total of 91 percent benefited. The female patients within this group had a 94 percent probability of benefit from operation. We conclude that most patients with myasthenia gravis will benefit from thymectomy, and that the improvement persists over an extended period of time in a high percentage of patients.

Surgical management of subaortic stenosis

The two most common causes for left ventricular outflow tract obstruction are discrete fibromuscular membrane (DMS) and idiopathic hypertrophic subaortic stenosis (IHSS). From 1955 to 1980, 195 patients were seen with subaortic obstruction, 50 of whom required operation. Thirty patients had excision of a subaortic membrane; 20 had resection of the hypertrophic muscular obstruction. The average preoperative gradient across the left ventricular outflow tract was 79 mm Hg. Postoperatively 40 patients were catheterized; two had gradients over 40 mm Hg, and both were in the DMS group. There were four operative and six late deaths (mean follow-up, 8.5 years), five occurring in the IHSS group (25%) and one in the DMS group (3.5%). Recurrent symptoms required reoperation in three patients with IHSS and one with DMS. Both groups benefitted from operation, but those with DMS had a better overall survival rate and fewer postoperative symptoms than those with IHSS.

Massive perioperative polyuria

A 25-year-old man with a spinal cord transection secondary to a gunshot wound underwent surgical repair of a perforated prepyloric ulcer on the eighth hospital day. He received 68 liters and excreted 43 liters of intravenous fluid during the perioperative period. Causes of this massive polyuria during and after the second operation are unknown, although iatrogenically induced glycosuria and natriuresis may have contributed to its severity. The problems and their management are discussed.

Novel evolutionary variation in transcription and location of two chloroplast genes

We have found major evolutionary changes in the types of transcripts produced by specific chloroplast genes, in particular those encoding the large subunit (LS) of ribulose-1,5-bisphosphate carboxylase and a photosystem II polypeptide (PII). Two distinct patterns of LS gene transcripts are revealed by hybridizing an LS gene probe to electrophoretically separated RNA from 19 angiosperms. Most species, including pea, contain the single transcript of approximately 1.6 kb previously observed in corn, spinach and mustard. However, in mung bean and other members of the legume genera Vigna and Phaseolus, the 1.6 kb transcript represents only a minor fraction of LS transcripts, and instead, two larger LS transcripts of approximately 2.4 and 2.6 kb predominate. The PII gene produces a single transcript in pea and most other species examined, while members of the related legume genera Vigna, Phaseolus and Glycine contain two additional transcripts which are smaller in size and probably represent specific RNA breakdown products. A single species, sweet pea (Lathyrus odoratus), contains a second PII transcript which is 0.2 kb larger than the approximately 1.2 kb transcript found in all species. The LS and PII genes map to the same 5 kb region in both pea and mung bean and are transcribed off the same DNA strand. In contrast, published studies indicate that the two genes are approximately 50 kb apart and are transcribed off opposite DNA strands in five other chloroplast genomes. These differences are probably the consequence of an approximately 50 kb inversion which distinguishes the pea and mung bean genomes from those of most other angiosperms (1).

Benefits of normothermic induction of blood cardioplegia in energy-depleted hearts, with maintenance of arrest by multidose cold blood cardioplegic infusions

This study tests the hypothesis that warm induction of cardioplegia prior to prolonged maintenance by multidose infusions of cold blood cardioplegic solution would increase the tolerance of energy-depleted hearts to subsequent aortic clamping. Eighty percent depletion of subendocardial adenosine triphosphate (ATP) was produced in 30 dogs by 45 minutes of normothermic ischemia. This was followed either by unmodified blood reperfusion or 2 additional hours of aortic clamping with multidose cold blood cardioplegia. We compared a brief (5 minute) period of 37 degrees C cardioplegic induction to standard 4 degrees C blood cardioplegic induction to determine if warm induction would enhance metabolic and functional recovery. Warm cardioplegic induction resulted in more oxygen consumption than cold induction (16.9 versus 8.1 cc/100 gm), and lower levels of glucose-6-phosphate (G6P), suggesting better aerobic metabolism (0.97 versus 1.87 microM/gm wet weight). Prompt repletion of creatine phosphate (CP) occurred with warm and cold cardioplegic induction, although ATP levels levels remained low. Hearts undergoing ischemia and unmodified reperfusion consumed insufficient oxygen to meet basal metabolic needs during reperfusion (7 cc/100 gm below requirement) and recovered only 33% +/- 5% of control left ventricular performance. Better function occurred with cold cardioplegic induction (63% +/- 5%), and almost complete recovery (85% +/- 5%) occurred when warm induction of cardioplegia was used. We conclude that warm induction followed by prolonged cold multidose blood cardioplegic arrest enhances aerobic metabolism, results in normal left ventricular performance, and improves tolerance of aortic clamping in energy-depleted hearts.

Postoperative deterioration in muscular function

To clarify the postoperative fatigue state, we analyzed some components of muscular function before and after surgical procedures. Eleven subjects undergoing elective surgery were studied for test periods of up to 35 days. Significant impairment of muscular functioning, particularly muscle endurance, developed postoperatively. Maximum deterioration was noted on postoperative days 8 and 9. Isometric strength was affected more than isokinetic strength. Changes in muscular functioning in two young volunteers undergoing bed rest were surprisingly similar to those observed in postoperative patients.

Nonoperative management of a traumatic peroneal artery false aneurysm

The standard approach to management of traumatic false aneurysms is operative. This report describes successful treatment of a traumatic peroneal artery aneurysm following a gunshot wound in a 29-year-old man by an intraluminal steel coil occlusion technique. The coil was guided through the popliteal artery and aneurysm into the distal peroneal artery via a percutaneously placed catheter: following disengagement of the coil the outflow tract of the aneurysm was occluded, and another passed and released into the proximal peroneal artery occluded the inflow tract.

Area variations in infant mortality 1975-7

Infant mortality rates vary from area to area. Part of this variation is due to the socioeconomic characteristics of the area and part to other factors including the obstetric, paediatric, and community health services. Four social indicators associated with infant deaths are used to control for some of the variations in socioeconomic characteristics and residual variation is then examined. The four social indicators are the level of unemployment, the proportion of large families, the proportion of lone-parent families, and the level of overcrowding.

Effect of cimetidine on serum calcium levels in an elderly patient

A 92-year-old woman with a normal serum calcium level received cimetidine postoperatively. She became severely hypocalcemic and exhibited tetany, seizures, and impaired mental status. Her condition responded to intravenous diazepam, phenytoin sodium, and gluconate calcium. Normal serum calcium levels were maintained by calcium infusions until the cimetidine treatment was stopped. Cimetidine may have been responsible for the observed complications due to its effect on serum parathyroid hormone level.