Lobar exclusion after transpericardial herniation in a heart-lung transplantation

Lobar herniation is a rare complication of heart-lung transplantation (HLT). We describe a case of right lower lobe herniation through the pericardial window into the left pleural space diagnosed 54 days after operation. Extensive adhesions precluded a lobectomy through a right thoracotomy approach, therefore the lobe was simply excluded and left in situ. The subsequent postoperative course, a CT-scan 2 years later and the 7 years survival time demonstrated that the lobe became fibrosed without any major sequelae.

Safety and efficacy of hydroxychloroquine as maintenance therapy for rheumatoid arthritis after combination therapy with methotrexate and hydroxychloroquine

OBJECTIVE

To evaluate the ability of hydroxychloroquine sulfate (HCQ) to extend the response to combination therapy with HCQ and methotrexate (MTX) and the safety of longterm HCQ maintenance therapy in patients with active rheumatoid arthritis (RA).

METHODS

Two-part study consisting of an open label segment evaluating combination HCQ/MTX therapy followed by a double blind segment evaluating maintenance therapy for a total of 60 weeks. First, all patients were treated with HCQ 400 mg/day and MTX 7.5 to 15 mg/week for 24 weeks. Then, responders were randomized into 3 groups: (1) HCQ with MTX as needed for disease flare (n = 40), (2) HCQ 400 mg/day (n = 41), or (3) placebo with MTX as needed for disease flare (n = 40), each for 36 weeks.

RESULTS

Clinical disease and laboratory variables improved significantly during initial combination therapy with HCQ and MTX. After MTX withdrawal, HCQ-containing maintenance regimens delayed the onset of disease flare (p = 0.023). There were no unexpected adverse events at any time or between-group differences in the distribution of adverse events during the double blind segment.

CONCLUSION

Combination of HCQ and MTX appeared to be effective and well tolerated for 24 weeks. After withdrawal of MTX, HCQ extended the response seen with combination therapy and was well tolerated for 36 weeks. Initial therapy with HCQ and MTX, followed by maintenance HCQ, may be a useful alternative for the treatment of RA.

Esophagectomy for cancer in the patient aged 70 years and older

BACKGROUND

Advanced age increases the risk of any major surgical intervention, particularly esophageal resection. High morbidity and increased mortality have been reported in operations for esophageal cancer in the elderly.

METHODS

To determine outcome, risk factors, and the advisability of esophageal resection in the elderly, a single-institution retrospective review was performed of esophagectomy for cancer over a 14-year period. From January 1, 1980, to December 31, 1993, 540 patients underwent esophageal resection for esophageal cancer. These patients were divided into two groups: group 1, n = 89, patients 70 years of age or older; and group 2, n = 451, patients younger than 70 years of age. The two groups were compared according to preoperative risk factors, morbidity rate, mortality rate, mean stay in the hospital after operation, and long-term survival.

RESULTS

Adenocarcinoma of the esophagogastric junction was the most common tumor in group 1 and was usually managed with a single incisional approach. There were no significant differences between the groups concerning morbidity (24.7% in group 1), mortality (7.8% in group 1), mean stay in the hospital (23.3 days in group 1), or long-term survival (59%, 23%, and 13% at 1, 3, and 5 years, respectively, in group 1).

CONCLUSIONS

These results suggest that esophagectomy can be performed in selected elderly patients without increasing morbidity or mortality and with long-term survival.

Rescue of cardiac alpha-actin-deficient mice by enteric smooth muscle gamma-actin

The muscle actins in higher vertebrates display highly conserved amino acid sequences, yet they show distinct expression patterns. Thus, cardiac alpha-actin, skeletal alpha-actin, vascular smooth muscle alpha-actin, and enteric smooth muscle gamma-actin comprise the major actins in their respective tissues. To assess the functional and developmental significance of cardiac alpha-actin, the murine (129/SvJ) cardiac alpha-actin gene was disrupted by homologous recombination. The majority ( approximately 56%) of the mice lacking cardiac alpha-actin do not survive to term, and the remainder generally die within 2 weeks of birth. Increased expression of vascular smooth muscle and skeletal alpha-actins is observed in the hearts of newborn homozygous mutants and also heterozygotes but apparently is insufficient to maintain myofibrillar integrity in the homozygous mutants. Mice lacking cardiac alpha-actin can be rescued to adulthood by the ectopic expression of enteric smooth muscle gamma-actin using the cardiac alpha-myosin heavy chain promoter. However, the hearts of such rescued cardiac alpha-actin-deficient mice are extremely hypodynamic, considerably enlarged, and hypertrophied. Furthermore, the transgenically expressed enteric smooth muscle gamma-actin reduces cardiac contractility in wild-type and heterozygous mice. These results demonstrate that alterations in actin composition in the fetal and adult heart are associated with severe structural and functional perturbations.

Cognitive screening instruments in neuropsychiatry: a report of the Committee on Research of the American Neuropsychiatric Association

A 1994 survey by the Research Committee of the American Neuropsychiatric Association revealed that 58% of respondents employed formal assessment of cognitive status; the Mini-Mental State Examination (MMSE) and neuropsychological testing were the commonest techniques. Literature review on common cognitive screening instruments found that the MMSE has widespread popularity, ease of use, and a large body of research demonstrating its sensitivity to common neuropsychiatric disorders. The Committee recommends that clinicians who employ the MMSE 1) use it as a minimum screening for cognitive dysfunction; 2) employ age- and education-normative corrections; and 3) supplement it with specific measures of spatial functions, delayed memory, and executive abilities. The Modified MMSE and the Neurobehavioral Cognitive Status Examination also show promise as screening tools.

Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: comparison with MRI/CT

The purposes of this study were: (1) to determine the prevalence of abnormal 99mTc-HMPAO SPECT scans in patients suffering from persistent post-concussive syndrome (PPCS) after mild closed head injury (CHI); (2) to compare SPECT with structural neuroimaging (MRI and CT) in patients with mild CHI; and (3) to investigate correlations between SPECT and clinical data obtained from the patient sample (neuropsychological testing, demographics, psychiatric diagnoses). Forty-three patients were included. SPECT was read as abnormal in 53% of patients and showed a total of 37 lesions while MRI was read as abnormal in 9% and CT scan in only 4.6% of patients after mild CHI. SPECT appears to be more sensitive in detecting cerebral abnormalities after mild CHI, especially in patients with PPCS symptoms, than either CT or MRI. No statistically significant relationship was found between SPECT scan abnormalities and age, past psychiatric history, history of substance abuse, or history of multiple CHI. Education level did not differ between patients with normal and abnormal SPECT. Current neuropsychiatric symptoms did not seem to have any impact on the results of SPECT scan.

Keratin 12-deficient mice have fragile corneal epithelia

PURPOSE

Expression of the K3-K12 keratin pair characterizes the corneal epithelial differentiation. To elucidate the role of keratin 12 in the maintenance of corneal epithelium integrity, the authors bred mice deficient in keratin 12 by gene-targeting techniques.

METHODS

One allele of murine Krt1.12 gene was ablated in the embryonic stem cell line, E14.1, by homologous recombination with a DNA construct in which the DNA element between intron 2 and exon 8 of the keratin 12 gene was replaced by a neo-gene. The homologous recombinant embryonic stem cells were injected to mouse blastocysts, and germ lines of chimeras were obtained. The corneas of heterozygous and homozygous mice were characterized by clinical observations using stereomicroscopy, histology with light and electron microscopy, Western immunoblot analysis, immunohistochemistry, in situ hybridization, and Northern hybridization.

RESULTS

The heterozygous mice (+/-) one allele of the Krt1.12 gene appear normal and do not develop any clinical manifestations (e.g., corneal epithelial defects). Homozygous mice (-/-) develop normally and suffer mild corneal epithelial erosion. Their corneal epithelia are fragile and can be removed by gentle rubbing of the eyes or brushing with a Microsponge. The corneal epithelium of the homozygote (-/-) does not express keratin 12 as judged by immunohistochemistry, Western immunoblot analysis with epitope-specific anti-keratin 12 antibodies, Northern hybridization with 32P-labeled keratin 12 cDNA, and in situ hybridization with an anti-sense keratin 12 riboprobe. Light and electron microscopy revealed subtle abnormalities in the corneal epithelia of -/- mice (i.e., a decrease in number of cell layers) and cytolysis of superficial cells, but the number of hemidesmosomes and desmosomes are normal in basal and suprabasal cells. The number of keratin intermediate filaments in basal and suprabasal corneal epithelial cells in -/- mice decreases, and they appear as dense bundles. This morphology is similar to that of keratin intermediate filaments in epidermal epithelial, cells but differs from that of normal corneal epithelial cells in which the keratins form fine filamentous networks. The superficial epithelial cells are devoid of keratin intermediate filaments and often detach from the corneal surface of -/- mice.

CONCLUSIONS

The presence of cornea-specific K3-K12 keratin pairs is essential for the maintenance of corneal epithelium integrity.

A diagnostic algorithm for distinguishing the eosinophilia-myalgia syndrome from fibromyalgia and chronic myofascial pain

OBJECTIVE

To develop a diagnostic algorithm for the eosinophilia-myalgia syndrome (EMS) that complements the existing case definition.

METHODS

We conducted a retrospective study using data on 59 clinical and laboratory variables from a consecutive referral cohort of 91 patients with EMS meeting the Centers for Disease Control and Prevention case definition. Age and sex matched controls included 93 patients with fibromyalgia and 99 patients with chronic myofascial pain. The study period was March 1989 to April 1992. Recursive partitioning was used to create a diagnostic algorithm.

RESULTS

In the 283 case patients and controls with disabling myalgias, 4 differentiating variables identified patients with EMS: extremity edema, leukocyte count > 12.5 x 10(9)/l, dyspnea, and absence of arthralgias. These 4 variables form a diagnostic algorithm that has a sensitivity of 95.6%, a specificity of 96.9%, and positive and negative predictive values of 93.5 and 97.9%, respectively.

CONCLUSION

This algorithm is practical and can be easily applied in any medical setting. It also readily distinguishes EMS from other common myalgia syndromes.

Cerebral ischemia in patients with hepatitis C virus infection and mixed cryoglobulinemia

We describe two women (ages 35 and 36 years) with cerebral ischemia, hepatitis C virus, and mixed cryoglobulinemia. One patient (case 1) was in otherwise good health when left parietal cerebral infarction developed, and she was found to have narrowing of the supraclinoid internal carotid artery siphon, anterior cerebral artery A1, and middle cerebral artery M1 segments bilaterally. Subsequent evaluation revealed abnormal liver enzymes, mixed cryoglobulinemia (type III), hypocomplementemia, and a high positive test result for rheumatoid factor. In the other patient (case 2), cerebral ischemia and seizures developed in the setting of previously documented mixed cryoglobulinemia (type II), membranoproliferative glomerulonephritis, and hypocomplementemia. In this patient, a brain biopsy demonstrated cerebral infarction. Hepatitis C virus infection was confirmed in both patients by polymerase chain reaction detection of hepatitis C virus RNA. These two cases document the occurrence of cerebral ischemia in patients with hepatitis C virus infection and mixed cryoglobulinemia. Testing for hepatitis C virus and cryoglobulins should be considered in selected patients with cerebral ischemia of inobvious cause.

MRI and neuropsychological differences in early- and late-life-onset geriatric depression

We sought to determine whether geriatric patients with late-life-onset major depression have more subcortical hyperintensities on MRI and greater cognitive impairment than age-matched geriatric patients with early-life-onset major depression, suggesting that subcortical disease may be etiologic in late-life depression. Most negative studies of the clinical significance of subcortical hyperintensities on MRI in geriatric patients have sampled from a restricted range of subjects, have employed limited batteries of neuropsychological tests, or have not quantified MRI changes; the present study attempted to address these limitations. Thirty subjects from a geriatric psychiatry inpatient service who were over 60 years of age and presented with major depression were divided into groups with onset of first depression after age 60 (mean = 72.4 years, 15 women, 0 men), and onset of first depression before age 60 (mean = 35.8 years, 12 women, 3 men). Quantitative analysis of MRI yielded the volume of: periventricular hyperintensities (PVH) and deep white-matter hyperintensities (DWMH). Subjects were administered a neuropsychological battery and measures of depression by raters blind to age of onset. The late-onset group had significantly more PVH and DWMH. They were also more impaired on executive and verbal and nonverbal memory tasks. Discriminant analysis using the severity or subcortical signal hyperintensities on MRI, cognitive index, and depression scores correctly predicted late versus early onset of depression in 87% of the early-onset group and 80% of the late-onset group. These findings suggest that late-life-onset depression may be associated with an increased severity of subcortical vascular disease and greater impairment of cognitive performance.

Quantitative analysis of hyaluronan in human synovial fluid using capillary electrophoresis

The glycosaminoglycan, hyaluronan, can be detected in human synovial fluid by capillary electrophoresis (CE). Variations in peak shape make this technique unsuitable for quantitative analysis of hyaluronan in raw synovial fluid. Quantitative analysis was achieved by hydrolysis of the polymeric hyaluronan to the tetrasaccharide by the action of testicular hyaluronidase and separation of the product using CE. A UV detector operating at 200 nm was used. The X-ray contrast material, omnipaque, a propriety aqueous solution of iohexol was used as internal standard. A second peak in the electropherogram of synovial fluid was quantified. The variation in concentrations of these two components correlate with the arthritic disease state of a joint.

A cardiovascular intensive care nursing staff response to managed care: a change in practice

Managed care has brought competition to the health care workplace. This competitive atmosphere creates challenges to attain quality outcomes while minimizing costs. A large community hospital in the mid-Atlantic region, in a collaborative effort with all members of the health care team, undertook the challenge to revise the way care was delivered to the cardiac surgical patient. This article will report the changes the cardiovascular intensive care nursing staff had to undergo and the methods that were used to incorporate these changes.

Alcohol, tobacco, illicit drugs, and sex: an analysis of risky behaviors among young adults

This paper reexamines data from two previous surveys. It looks at self-reported alcohol, tobacco, and illicit drug use and sexual risk-taking among three subgroups of young adults. All subjects (N = 1,387) were aged 20-30. The samples consisted of nurses in the Lothian Region, and residents in Muirhouse (Edinburgh) and Easterhouse (Glasgow). Factor analysis revealed that risk-taking behavior was neither entirely general nor entirely specific. Although there was some tendency for a risk-taker in one area to be a risk-taker in others, five fairly distinct types of risk-taking could be distinguished. These included sexual risk-taking, illicit use of drugs, and excessive alcohol consumption. The samples differed in the extent to which they indulged in the different types of risk-taking, and various other predictors of these behaviors were found. Different patterns of association emerged in relation to specific subgroups of respondents.

Apathy: a treatable syndrome

Apathy occurs frequently in neuropsychiatric disorders both as a symptom of other syndromes and as a syndrome per se. Histories are presented of patients with a syndrome of apathy who showed clinically significant, sustained benefit from pharmacological treatment. Etiologies included non-Alzheimer's frontal lobe dementia, cerebral infarction, intracranial hemorrhage, alcoholism, and traumatic brain injury. Agents included amantadine, amphetamine, bromocriptine, bupropion, methylphenidate, and selegiline. These histories support the suggestion that apathy is a discriminable dimension of behavior having its own pathophysiology and implications for psychiatric care. They raise the possibility of treatment for many patients previously thought untreatable. Studying the treatment of apathy may contribute to the clinical care and scientific understanding of neuropsychiatric disorders throughout the life span.

Multiple spuriously abnormal thyroid function indices due to heterophilic antibodies

A 57-year-old man with a history of liver fibrosis, portal hypertension and hypersplenism had thyroid function assessed because of weight loss. Free T4 (FT4), total T4 (TT4), total T3 (TT3) and TSH were all assayed by enhanced chemiluminescent immunoassay. This demonstrated elevation of all three hormones. Because of the atypical profile obtained and because the patient appeared to be euthyroid, re-assay of the patient's serum was performed following immunoglobulin precipitation with 50% polyethylene glycol. The levels of T4 and T3 were then found to be within the reference ranges suggesting that the serum contained interfering immunoglobulins. Anti-immunoglobulin antibodies also neutralized the interfering substances present in the patient's serum. These observations indicate that non-specific immunoglobulins present in the patient's serum cross-reacted with the antibodies employed in the assays used, giving rise to spurious results. To our knowledge, this is the first report of artefactual elevation of results obtained by T4, T3 and TSH assays of a serum occurring as a result of interfering immunoglobulins. Their presence became apparent only because of the very rare coincidence of antibodies interfering with more than one assay giving rise to an atypical hormone pattern. The frequency of this phenomenon affecting a single assay and therefore more likely to go undetected, is unknown and is a cause for concern.

Two-generation reproduction study on commercial hexane solvent

The reproductive effects of inhalation exposure to commercial hexane vapors were evaluated in Sprague-Dawley rats. Males and females were exposed to commercial hexane vapor at target concentrations of 0, 900, 3000 or 9000 ppm for 6 h a day, 5 or 7 days a week, over two generations. In addition to pre-breed exposures of 10 weeks' duration, exposures continued through mating, gestation and lactation. At both the F0 breed to produce F1 litters and the F1 breed to produce F2 litters, reproductive parameters were unaffected by commercial hexane exposure. The mating, fertility and gestational indices, as well as litter size and postnatal survival, were not significantly different between exposure groups. However, reductions in body weight and body weight gain were observed in both F1 and F2 litters exposed to 9000 ppm. Effects on body weight were not observed in offspring exposed to the two lower concentrations of commercial hexane. Histopathological examination of selected tissues revealed hyaline droplet nephropathy in adult F0 and F1 males exposed to 9000 ppm. This finding was anticipated and is not believed to be relevant for the assessment of human health effects. No other treatment-related histopathological lesions were observed. Thus, exposure of rats to commercial hexane for two generations resulted in reduced body weight gains at 9000 ppm but no adverse effects on reproduction. These findings suggest that occupational exposure to commercial hexane vapors at currently recommended threshold limit value concentrations (i.e. TLV for n-hexane is 50 ppm and TLV for other hexane isomers is 500 ppm) should not pose a reproductive hazard.

The performance of intensive care units: does good management make a difference?

A significant portion of health care resources are spent in intensive care units with, historically, up to two-fold variation in risk-adjusted mortality. Technological, demographic, and social forces are likely to lead to an increased volume of intensive care in the future. Thus, it is important to identify ways of more efficiently managing intensive care units and reducing the variation in patient outcomes. Based on data collected from 17,440 patients across 42 ICUs, the present study examines the factors associated with risk-adjusted mortality, risk-adjusted average length of stay, nurse turnover, evaluated technical quality of care, and evaluated ability to meet family member needs. Using the Apache III methodology for risk-adjustment, findings reveal that: 1) technological availability is significantly associated with lower risk-adjusted mortality (beta = -.42); 2) diagnostic diversity is significantly associated with greater risk-adjusted mortality (beta = .46); and 3) caregiver interaction comprising the culture, leadership, coordination, communication, and conflict management abilities of the unit is significantly associated with lower risk-adjusted length of stay (beta = .34), lower nurse turnover (beta = -.36), higher evaluated technical quality of care (beta = .81), and greater evaluated ability to meet family member needs (beta = .74). Furthermore, units with greater technological availability are significantly more likely to be associated with hospitals that are more profitable, involved in teaching activities, and have unit leaders actively participating in hospital-wide quality improvement activities. The findings hold a number of important managerial and policy implications regarding technological adoption, specialization, and the quality of interaction among ICU team members. They suggest intervention "leverage points" for care givers, managers, and external policy makers in efforts to continuously improve the outcomes of intensive care.

Cytogenetic studies on commercial hexane solvent

Commercial hexane is a solvent mixture of six-carbon isomers, consisting principally of n-hexane, 3-methylpentane, methylcyclopentane and 2-methylpentane. The potential of commercial hexane to produce chromosome aberrations was evaluated in both an in vitro assay using Chinese hamster ovary (CHO) cells and an in vivo cytogenetics assay using Sprague-Dawley rats. The CHO cells were exposed to media containing commercial hexane at concentrations of 0.014-0.42 microliters ml-1 in the presence and absence of an S-9 activation mixture. Cellular toxicity was observed at the higher dose levels, but no increase in chromosome aberrations was observed in either the non-activated or S-9-activated systems. For the in vivo cytogenetics assay, rats were exposed nose-only for 6 h per day for 5 consecutive days to commercial hexane vapor at target concentrations of 900, 3000 and 9000 ppm. Bone marrow cells were collected at 6 and 24 h after the midpoint of the last exposure. Metaphase cells were examined microscopically for chromosome aberrations. No statistically significant increases in aberrant cells were observed in the commercial hexane-exposed animals of any dose group at either of the bone marrow harvest times. In conclusion, commercial hexane did not produce chromosomal mutations under the conditions of these studies.