First-pass radionuclide angiography via pulmonary arterial catheters. A critical analysis of background components

Residual background activity following first-pass radionuclide angiography was assessed in 44 patients after eliminating activity in the right heart, left lung, and most of the right lung. The ejection fraction (EF) was calculated in two ways: (a) assuming background activity was present only in the right heart and lungs, and (b) correcting for scattered radiation by placing a circular region of interest around the left ventricle. With the first method, contrast EF was significantly underestimated in both AP and RAO views. With the second method, correlation was close in both views and absolute values agreed well with contrast EF. These results indicate that there is a substantial and measurable background component, due mainly to Compton scatter, even when activity from the right heart and lungs is eliminated.

Intramural intestinal hematoma causing obstruction in three dogs

Intramural hematoma of the intestine caused intestinal obstruction in three dogs. Two dogs were examined because of vomiting and anorexia of several weeks' duration. In one of these, an intramural hematoma of the duodenum was associated with chronic pancreatitis. A cause was not found in the second dog. The third dog, which had clinical and radiographic evidence of gastric dilatation, was found at surgery to have hemoperitoneum associated with a ruptured intramural intestinal hematoma. In 1 dog, the hematoma was evacuated through a serosal incision. In the other 2 dogs, the problem was resolved by resection of the involved segment of intestine, followed by anastomosis. All 3 dogs recovered without complications.

Southeastern Cancer Study Group: breast cancer studies 1972-1982

During the past 10 years, the Southeastern Cancer Study Group (SECSG) has been engaged in one major adjuvant study and three major advanced disease studies for patients with adenocarcinoma of the breast. The adjuvant study is demonstrating that six months of adjuvant CMF is the therapeutic equivalent of 12 months and that post-operative irradiation is of no added therapeutic benefit. In patients with advanced disease, a low dose 5 drug combination of CMFVP induces more objective responses than single agent 5FU, but improves survival only for those patients with liver metastases when compared to the sequential use of the same 5 single agents. The three drug combination, CAF, utilizing doxorubicin, induces more objective responses than low dose CMFVP, but it does not improve overall survival. The subsets of patients with bone-only metastases, with local chest wall recurrence and with nodular lung metastases benefit from CAF in terms of a longer duration of disease control and longer duration of unmaintained remission, but have only a marginal improvement in survival. The addition of a phase active combination, CAMELEON, (i.e., sequentially alternating therapy) to CAF has not improved the duration of disease control and survival for patients with liver metastases, lymphangitic and nodular lung metastases compared to CAF. Aggressive combination chemotherapeutic approaches to patients with advanced disease provide better and longer disease and tumor control but only marginal improvements in overall survival. Adding additional agents to a maximally tolerable regimen has not improved the therapeutic outcome.

A comparison of cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) and cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, and prednisone (CMFVP) in patients with advanced breast cancer

The Southeastern Cancer Study Group, in a prospectively randomized study involving patients with advanced breast cancer, has compared a low dose intermittently administered five-drug regimen including cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, and prednisone (CMFVP) with an aggressively administered three-drug regimen including cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF). CAF induced more responses and more complete responses and a longer duration of disease control. However, only a marginal difference was demonstrated in overall survival between the two regimens (p = less than 0.10). Patients with a good risk pattern of metastases, i.e. those with nodular local chest wall recurrence, nodular pulmonary metastases, or bone-only metastases were more likely to achieve a response and survive longer than those with a poor risk pattern, i.e. lymphangitic pulmonary metastases, pleural effusion with chest wall ulceration, or widespread metastases, including hepatic. All of the differences between the two regimens were noted in the good risk pattern groups. CAF provided no additional benefit to patients presenting with poor risk patterns of metastases. Adriamycin-containing combinations may achieve a greater degree of tumor cell kill in certain subsets of patients with advanced breast cancer, but this provides only a marginal increase in survival.

Effect of warm-up on left ventricular response to sudden strenuous exercise

Sudden strenuous exercise (SSE) has been shown to produce ischemic electrocardiographic (ECG) responses, abnormalities of myocardial blood flow, and decreases in left ventricular ejection fraction. Prior exercise taken as warm-up has been shown to ameliorate the ECG and myocardial blood flow abnormalities induced by SSE. The purpose of this study was to determine whether warm-up would normalize the responses of the left ventricular ejection fraction to SSE. Twenty healthy male volunteers performed SSE (400-W bicycle exercise) either with (group A, n = 10) or without (group B, n = 10) warm-up. Ejection fraction was measured using first-pass radionuclide angiography under control conditions and during SSE. During SSE ejection fraction decreased from control values in both group A (70.5 +/- 6.3 to 64.8 +/- 8.2%) and group B (70.3 +/- 10.1 to 57.7 +/- 7.7%), although ejection fraction was significantly higher during SSE in group A. The results are consistent with the hypothesis that the abnormal responses to SSE are attributable to subendocardial ischemia secondary to a delay in autoregulation of myocardial blood flow. However, the decrease in ejection fraction during SSE even following warm-up suggests that the mechanism for the abnormal response to SSE is more complicated than previously hypothesized.

Effect of habitual exercise on left ventricular response to exercise

To evaluate the effects of chronic physical exercise on left ventricular ejection fraction (LVEF) and ejection rate (LVER), radionuclide angiography was performed at rest and during upright-bicycle exercise in 45 healthy men. The subjects varied widely in exercise habits and working capacity. They were divided into three subgroups on the basis of habitual physical activity. Aerobic training was done more than 7, 2-4, and less than 1 h/wk by subgroups of athletes, trained, and untrained men, respectively. The results indicate marked differences in work capacity (298, 233, and 181 W in the athletes, trained, and untrained groups, respectively). Resting LVEF (72, 69, and 68%) and LVER (4.1, 3.4, and 3.6 s-1) were not significantly different among the groups. With maximal exercise, however, small but statistically significant differences in LVEF (75, 69, and 68%; P less than 0.05 athletes vs. trained and athletes vs. untrained) and in LVER (7.5, 6.3, and 5.2 s-1; P less than 0.05 among all groups) were observed. Work capacity was, however, poorly correlated with exercise LVEF (r = 0.18) and LVER (r = 0.47). The results of this study indicate that the enhanced working capacity observed secondary to increases in habitual physical activity can be attributed to differences in LVEF and LVER only in the most general terms. Accordingly the results agree with previous suggestions based primarily on echocardiographic data that the primary cardiac adaptation to exercise is dimensional rather than functional in character.

Left ventricular function at rest, peak exercise and postexercise

To determine whether the temporal sequence of imaging could influence the results of exercise radionuclide angiography, 15 healthy volunteers were studied at rest, during peak bicycle exercise and immediately postexercise using first pass radionuclide angiography. Responses at rest, peak and postexercise included: heart rate (67 to 174 to 170 bpm), double product (7.4 to 31.5 to 27.5 mm Hg X bpm X 10(3)), left ventricular ejection fraction (68 to 69 to 80%) and mean normalized left ventricular ejection rate (3.63 to 6.56 to 8.56 s-1). The results indicate that left ventricular ejection fraction and mean normalized ejection rate were different during exercise and immediately postexercise although heart rate and double product were not. The results indicate that the temporal sequence of imaging is a significant procedural variable in the conduct of exercise radionuclide angiography.

Left ventricular function during sudden strenuous exercise

Strenuous exercise without warm-up has been shown to produce ischemia-like electrocardiographic (ECG) abnormalities in 60-70% of healthy subjects. These abnormalities appeared to be related to the development of an unfavorable myocardial supply/demand balance and, in chronically instrumented dogs, to transient decreases in coronary blood flow. A mechanism involving subendocardial ischemia has been proposed to explain the response to sudden strenuous exercise (SSE). To determine whether the response to SSE included the development of changes in myocardial pump performance typical of ischemia, left ventricular (LV) function at rest, during graded exercise and during SSE was evaluated in nine young (26.6 +/- 3.4 years), well-trained male volunteers using first-pass radionuclide angiography. During graded exercise, the LV ejection fraction increased from 66.9 +/- 9.4% at rest to 73.0 +/- 7.1% during peak exercise, and the LV ejection rate increased from 3.36 +/- 0.67 sec-1 at rest to 6.58 +/- 1.10 sec-1 during peak exercise. Segmental wall motion was normal in all studies. During SSE, the LV ejection fraction decreased in very subject, from an average 72.2 +/- 8.6% at rst to 57.3 +/- 8.1% during exercise. The LV ejection rate remained relatively constant (3.98 +/- 0.92 sec-1 at rest vs 4.33 +/- 0.74 sec-1 during SSE). No segmental wall motion abnormalities were observed during SSE; however, LV wall motion appeared to be diffusely hypokinetic during SSE. In contrast to previous reports, few ECG abnormalities were observed during SSE. These results support the hypothesis that subendocardial ischemia is an important mechanism in the response to SSE. However, the lack of ECG changes and segmental wall motion abnormalities and the relatively high absolute value of the LV ejection fraction suggest that if subendocardial ischemia occurs during SSE, it is attributable to physiologic rather than pathologic mechanisms.

Neutropenia induced by semisynthetic penicillin

The semisynthetic penicillins, like the parent drug penicillin G, are remarkably safe drugs. However, a significant number of patients have been reported in whom profound neutropenia has developed. This is a side effect of these drugs not appreciated by a significant number of physicians. I report two more cases of neutropenia due to nafcillin and review the literature on neutropenia induced by semisynthetic penicillin. The relative risk of each individual drug is evaluated, and the two proposed mechanisms of production of the neutropenia are discussed.

Phenytoin hypersensitivity presenting as postoperative fever

One of the most catastrophic complications of intracranial surgery is infection. These infections present frequently as postoperative fever and a change in sensorium. Phenytoin is used frequently in conjunction with intracranial operation to prevent seizures. We report two patients in whom, although the full phenytoin sensitivity syndrome ultimately developed, the presenting sign was postoperative fever. The phenytoin sensitivity syndrome is reviewed with emphasis on the fact that all components of the syndrome are not always present initially. The clinical significance of the presentation of phenytoin hypersensitivity as postoperative fever is discussed.

Urinary hexosaminidase in patients with lung carcinoma

The specific activity of urinary hexosaminidase was determined in 58 patients with various histological types of lung carcinoma. Compared to an apparently healthy control population, 32/35 patients with widely disseminated disease showed elevated values and 18/23 patients with disease confined to the chest had normal hexosaminidase values. Detailed studies of 18 patients indicated that declining hexosaminidase values were associated with effective therapy, rising values generally accompanied progressive disease.

Keeping abreast of the times: the Tauranga Infant Feeding Survey

An infant feeding survey revealed that 77% of 187 mothers, whose babies were born over a three month period in the Tauranga maternity annexe, were breast feeding on discharge. Fifty-seven percent of the total breast fed for at least three months. The feeding pattern did not vary with ethnic group nor with previous breast feeding experience. Short-term breast feeders were younger and had fewer children than either the bottle feeders or long-term breast feeders. Bottle feeding tended to occur with extremes of maternal age. Breast feeders sought more advice during pregnancy and confinement. Overall, the most common reason for changing to bottle feeding was "insufficient lactation", although this reason rarely stood alone. Many mothers experienced difficulties with artifical feeds and made at least one milk change, nearly half receiving no advice. Solid food was most commonly introduced at three months.

A comparison of cyclophosphamide, adriamycin, 5-fluorouracil (CAF) and cyclophosphamide, methotrexate, 5-fluorouracil, vincristine, prednisone (CMFVP) in patients with metastatic breast cancer: a Southeastern Cancer Study Group project

In an ongoing prospective randomized study, 113 evaluable patients have received either a three-drug combination that included cyclophosphamide, Adriamycin and 5-fluorouracil (CAF) or a five-drug combination including cyclophosphamide, methotrexate, 5-fluorouracil, vincristine and prednisone (CMFVP) given intermittently 1 week out of 4. Responses (64%), median duration of response (32 weeks), and median duration of disease control (32 weeks) achieved with CAF were superior to those achieved with CMFVP (37%, 22 weeks, 17 weeks, respectively). Morbidity secondary to CAF was significant, with nausea and vomiting, malaise, total alopecia, and granulocytopenia being the main features.

Amniotic fluid neutrophils prior to Cesarean section and intrauterine infection

Amniotic fluid from 35 patients delivered by cesarean section was examined by Wright's stain. Of the patients in labor and with rupture of the membranes, 32% had more than 1 polymorphonuclear neutrophil per oil field (PMN/OF) while 68% had less than 1 PMN/OF. In both groups, endometritis occurred frequently, and fever indexes were similar. With ruptured membranes prior to cesarean section, observing greater than 1 PMN/OF of amniotic fluid did not discriminate groups at high and low risk for intrauterine infection.

The predictability of intrauterine infection by analysis of amniotic fluid

Amniotic fluid samples from 95 internally monitored patients were examined to determine whether the appearance of polymorphonuclear leukocytes or bacteria could predict intrauterine infection. All patients delivered vaginally. More than one polymorphonuclear leukocyte per oil field were seen in specimens of 32% of patients; bacteria were seen in specimens of 52% of patients, and organisms were grown in 93% of specimens, yet, the overall maternal infection rate was only 6.3%. Moreover, infection developed in only 10% of patients with polymorphonuclear leukocytes in the fluid and 6% of patients with positive gram stain or cultures. For patients who deliver vaginally, the appearance of polymorphonuclear leukocytes or bacteria does not predict infection.