Serum immunoreactive anodal trypsinogen and urinary amylase as biochemical markers for rejection of clinical whole-organ pancreas allografts having exocrine drainage into the urinary bladder

Rejection of pancreas allografts is best measured today by co-monitoring the creatinine of a simultaneously transplanted kidney allograft from the same donor. This methodology discourages pancreas transplantation for patients who have previously received a kidney allograft and preuremic patients. Thus, an early, graft-specific marker of rejection is desirable. In this study we compared 2 putative biochemical markers for rejection of pancreas allografts, serum immunoreactive anodal trypsinogen and urinary amylase, with serum creatinine in 15 simultaneously transplanted type I diabetics. Serial values during hospitalizations were determined. Follow-up ranged from 18 to 134 postoperative days. Rejection was diagnosed clinically and considered real if the patient received a course of anti-rejection medication. Ten of these 15 patients experienced a total of 21 rejection episodes. For all episodes of rejection, serum trypsinogen rose from a baseline of 398.1 +/- 25 ng/ml to 1686.2 +/- 317.9 ng/ml (P less than 0.001) on the day of rejection. Urinary amylase fell from 88,310 +/- 7877 U/24 hr to 37,508 +/- 7142 U/24 hr (P less than 0.001). For 10 patients in whom rejection was diagnosed on the initial hospitalization so that serial prediagnosis sera and urines were available, anodal trypsinogen rose from a baseline of 756 +/- 263 ng/ml to 1936 +/- 582 ng/ml (P less than 0.001). Urinary amylase values for these same 10 patients did not change significantly (baseline = 55,788 +/- 18,404 U/24 hr, rejection = 47,133 +/- 14,737 U/24 hr, (P = 0.7). We conclude that serum anodal trypsinogen behaves as a graft-specific biochemical marker for rejection of vascularized pancreas allografts.

A study of the potential pharmacokinetic interaction of lisinopril and digoxin in normal volunteers

1. The pharmacokinetics of single oral doses of 20 mg lisinopril and 0.25 mg digoxin, given alone and together, have been studied in 12 normal young male volunteers. 2. Peak serum conc of lisinopril occurred at 6 to 8 h and were slightly higher during combined treatment. Subsequent elimination proceeded moderately rapidly in both cases, concn declining to approx. 25% of peak values in 24 h. The AUC of lisinopril was similarly slightly higher during combined treatment. 3. After lisinopril alone, urinary elimination of unchanged lisinopril was 13% dose in 72 h, and after combined therapy was 17% dose. 4. Although there were no statistically significant differences in lisinopril pharmacokinetics during single or combined treatment, serum and urinary parameters suggest that bioavailability may be enhanced slightly during combined treatment. 5. Plasma concentrations of digoxin were slightly lower and urinary excretion slightly higher during combined treatment, the mean renal clearance being 20% higher.

Basal metabolism of obese adolescents: inconsistent diet and exercise effects

Effects of 20 wk of diet-plus-behavior (DB) therapy or exercise-plus-diet-plus-behavior (EDB) therapy on changes in basal energy expenditure (BEE) were studied in 36 obese male and female adolescents. BEE was assessed by open-circuit spirometry and body composition by hydrostatic weighing. Dietary restriction was based on the dietary-exchange program. Behavioral treatment included record-keeping, stimulus-control, and reinforcement techniques. EDB therapy included 50 min/d, 3 d/wk of aerobics. A time-by-group (2 X 3) repeated-measures ANOVA was used to analyze pre-to-postintervention differences between groups (DB, EDB, and control). Results revealed small but statistically significant (p less than 0.05) differences in body composition between the two experimental groups and control subjects. There were no differences in body composition between the DB and EDB groups, although all control subjects gained body mass (p less than 0.05). There was no group-by-time interaction for BEE. Moderate correlations of r = less than or equal to 0.61 were obtained between change in BEE and change in body composition for the subjects in the experimental groups.

Thymoma and aregenerative anemia

Among 32 patients with thymoma treated at the Louisiana State University Medical Center, there was one patient with aregenerative anemia attributable to thymoma (an incidence of 3.3%). Despite successful surgical removal of the thymoma, there was only slight improvement of the hematologic status three years after thymectomy. The result in this patient approximates the general experience, with hematologic remission being likely in less than 20% of cases. Experience casts doubt on whether treatment with adrenocortical steroids, mediastinal irradiation, or splenectomy provides significant beneficial effects.

Circulating concentrations of porcine ileal peptide but not hexosaminidase are elevated following 1 hr of mesenteric ischemia

Porcine Ileal Peptide (PIP) is located in the mucosa of the small bowel. We hypothesized that PIP may be useful as a marker for early intestinal ischemia or other acute processes of the mucosa. To test this hypothesis we developed a model of acute reversible intestinal ischemia in the pig. Following isolation of a 100-cm segment of ileum on a vascular pedicle baseline, serum and tissue samples were obtained. The vessels were then occluded for 60 min and the segment was reperfused. Serial serum samples were taken and analyzed for PIP and hexosaminidase (HEX). HEX enzyme activity in serum is known to be elevated in animals having intestinal necrosis. The Student t test for paired data was used. In preliminary studies we found that circulating HEX activity became elevated following 3 to 4 hr of vessel occlusion followed by reperfusion. In the current experiments, following 1 hr of ischemia, PIP rose significantly in the peripheral circulation, being 153.8 +/- 76.8, 909.0 +/- 150.4, and 898.3 +/- 128.1 ng/ml (P less than 0.001) at 0, 60, and 360 min after reperfusion of the segment. HEX on the other hand did not change significantly throughout the experiment, having been 766.0 +/- 28.1, 752.0 +/- 71.3, and 780.1 +/- 53.7 nM/liter (ns) at 0, 60, and 360 min following reperfusion of the segment. Histology demonstrated some clubbing, shortening and fracturing of villi with thinning of the tips of the villi in many cases. Immunospecific staining for PIP was present along the intact borders of the villi.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood pressure in obese adolescents: effect of weight loss

The BP distribution of a group of 72 obese adolescents was determined both before and after weight loss. Weight loss was produced by a program of caloric restriction and behavior change alone (n = 26) or with a combination of caloric restriction, behavior change, and exercise (n = 25). It was demonstrated that obese adolescents have a BP distribution that is skewed 1 SD to the right of normal (P less than .01), and that with weight loss this distribution was no longer different from that of the general population. It was also shown that a weight loss program that incorporates exercise and caloric restriction produces the most desirable effect on BP reduction (ie, greatest decrease in resting systolic BP and greatest decrease in exercise diastolic and mean BP). Finally, it was demonstrated that obese adolescents have structural changes present in the forearm resistance vessels and that these structural changes are reversed to the greatest extent in the weight loss program that includes exercise.

Chylothorax causing reversible T-cell depletion

Study of a patient with traumatic chylothorax after blunt chest trauma defines the changes in cellular immunocompetence during nonoperative management and emphasizes the importance of defining these parameters in addition to documenting the effects of metabolic deterioration.

Dose-ranging study of isosorbide-5-mononitrate in chronic congestive heart failure treated with diuretics and angiotensin-converting enzyme inhibitor

The hemodynamic response of isosorbide-5-mononitrate (IS-5-MN) to the addition of the widely used therapy of diuretic drugs and the maximally tolerated dose of enalapril for heart failure was assessed in 8 patients with congestive heart failure (CHF) (New York Heart Association class II and III). The diuretic therapy was furosemide, 40 to 80 mg/day, with or without amiloride, 5 to 10 mg/day. The dose of enalapril was 5 to 20 mg/day. Four hours after the administration of the morning dose of enalapril, a Swan-Ganz catheter was positioned in the pulmonary artery. Patients received increasing doses of IS-5-MN to produce a satisfactory decrease in pulmonary capillary wedge pressure. Two of the first 3 patients studied had a large reduction in blood pressure when given 10 mg of IS-5-MN. Subsequent patients were therefore given an initial dose of 5 mg, the total dose being 5 to 20 mg over 2 hours. Results at baseline and 1 hour after the final dose of IS-5-MN are expressed as mean +/- standard deviation. Both pulmonary artery systolic and diastolic pressures decreased significantly (p less than 0.05) by 12.2 +/- 8.9/4.2 +/- 5.2 mm Hg, from 47.2 +/- 16.0/21.6 +/- 6.0 mm Hg to 35.0 +/- 15.2/17.4 +/- 9.3 mm Hg. Pulmonary capillary wedge pressure decreased by 8.6 +/- 4.4 mm Hg, from 22.1 +/- 5.4 to 13.6 +/- 7.5 mm Hg (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen uptake and energy output during walking of obese male and female adolescents

Oxygen uptake and steady-rate energy output of 7 obese male and 13 obese female adolescents (greater than 178% ideal body weight) walking at four different speeds (1.167, 1.5667, 1.7833, and 2.125 m/s) were studied. Body composition was measured by hydrostatic weighing, and steady-rate energy output by open circuit spirometry. Energy output was expressed as kJ/min (kcal/min) and indexed to body mass and fat-free mass. A 2-by-4 ANOVA (sex by speed) revealed significant differences in the energy output between the speed conditions. There was no significant difference between the sexes. A nonlinear increase in calorie output with increasing speed indicated a decreasing efficiency with increasing speed of walking. Possible reasons include biomechanical factors such as increased upper-body forward lean needed to maintain balance at faster speeds of movement, increased energy output due to increased inertia, extra energy output needed to accelerate the limbs and torso, and increased body fat.

The embryologic basis of tracheobroncho-pulmonary maldevelopment

An integrated analysis of 15 patients with tracheobronchial abnormalities, bronchogenic cysts and pulmonary sequestration demonstrates that these diverse clinical conditions are expressions of basic embryologic maldevelopment patterns. The clinical conditions described are indicative of differences in degree of the embryologic disorder. In addition to the clinico-pathologic changes affecting the tracheobroncho-pulmonary components of the respiratory system, the importance of aberrant pulmonary arterial blood vessels is described and the diagnostic importance of ancillary investigations is emphasized.

Outpatient surgery for prolapsed lumbar disc

A selected series of 14 patients with lumbar disc prolapse causing sciatica have been operated successfully with outpatient (daycase) surgery. Postoperative pain has been much less than expected. This form of surgery has proved very acceptable to patients and to their family doctors.

Biological and technological variability of residual lung volume and the effect on body fat calculations

Ten subjects were studied to determine within-subject variance (Swi2), and its components, biovariability (Si2) and technological error (Se2) of residual lung volume (RLV). Each subject's RLV was determined 18 times using the oxygen dilution method (O2D) over a 5-day period. Se2 was measured using a 9.0 l spirometer as a simulated subject and estimating its added space by the O2D method for 20 repeat trials. The mean +/- SD of RLV across subjects was 1.408 +/- 0.3143 l. The average Swi2 for the 18 trials was 0.0054 (Swi = +/- 0.0735 l). The variance associated with a trend effect (variance of mean trial scores, Sc2) was 0.00050 (Sc = +/- 0.0224 l). Se2 was found to be 0.00104 (Se = +/- 0.0323 l). Si2 calculated by subtracting Se2 and Sc2 from Swi2, was 0.0039 (Si = +/- 0.0621 l). It was demonstrated that body fat weight calculations can vary because of the within-subject variability in RLV. The calculated reliability of RLV across subjects was r = 0.95. It is concluded that RLV determined by the O2D method is very reliable. Moreover, biological variance accounts for 72% of Swi2 while technological variance and trend effect variance account for 19 and 9% of Swi2 respectively.

Surgical treatment of left ventricular aneurysms

An analysis of 37 patients surgically treated for left ventricular aneurysms provides preoperative clinical information regarding surgical risk. Operative mortality can be correlated with clinical and cardiac functional data as well as with the extent of coronary artery disease. Review of operative mortality in relation to the surgical procedure and the functional status of survivors indicates that aorto-coronary bypass grafting, complementary to aneurysmectomy, not only relieves angina pectoris, but also improves the functional status of the residual myocardium.

Validity and reliability of cardiac output by CO2 rebreathing

This article reviews the available literature on the validity and reliability of the non-invasive techniques, commonly known as CO2 rebreathing, for estimating cardiac output. The differing indirect methodologies are described and illustrated. A table, constructed from the available literature, comparing criterion versus estimated cardiac outputs is presented. The varying combinations of methods employed, differing measurement conditions, i.e. rest and exercise, and divergent populations are illustrated and discussed. The correlation between criterion and estimated cardiac output for these studies ranged from r = 0.09 to 0.96, with a % standard deviation of the differences of 1.5 to 176.8%. The Collier and end-tidal methods, in conjunction with either the Comroe or McHardy CO2 dissociation curve appears to be the most established, valid and reliable combination of methods for estimating resting cardiac output. These methods appear to be comparable to the combination of the Defares, end-tidal and Comroe curve methods for estimating cardiac output during exercise. Because of the potential for large errors, caution is urged when interpreting cardiac output results based on indirect estimation for individual assessment, or for subjects with certain types of pulmonary or heart diseases.

Hepatic tumors and oral contraceptives: surgical management

The clinical and pathological features of 14 patients with benign liver tumors are reviewed. There were two males and 12 females in this series of cases. All but one of the females had been on contraceptive steroid therapy for an average of 7.8 years. Abdominal pain was the presenting complaint in 75% of cases, a palpable abdominal mass was present in 22%, while 12.5% of the patients presented with acute hemorrhagic shock due to rupture of a liver cell adenoma. Liver cell adenomas (LCA) were found in 87.5% of the cases and a diagnosis of focal nodular hyperplasia (FNA) was made at histologic examination of the resected tumors in 12.5% of cases. Surgical resection of the liver tumors was performed successfully in 89% of the cases. Hepatic lobectomy was accomplished in four patients, hepatic segmentectomy was possible in three cases, while local wedge resection or focal excision were indicated on seven occasions. There was no operative mortality in this series, but one patient required reoperation for drainage of a complicating subphrenic abscess.

Double-blind, multicenter controlled trial comparing topical dimethyl sulfoxide and normal saline for treatment of hand ulcers in patients with systemic sclerosis

A prospective, randomized, double-blind trial compared topical therapy with 0.85% normal saline, 2% dimethyl sulfoxide (DMSO), and 70% DMSO for treatment of digital ulcers in 84 patients with systemic sclerosis. There were no statistically significant differences among the 3 treatment groups in the improvement in the total number of open ulcers, total surface area of open ulcers, average surface area per open ulcer, number of infected ulcers, number of inflamed ulcers, or patient pain assessment. While some patients improved during the study, improvement could not be attributed to a specific treatment. Over one-quarter of the patients treated with 70% DMSO were withdrawn for significant skin toxicity.

Basal metabolism of obese adolescents: age, gender and body composition effects

Body composition (percent fat and lean body mass) and basal metabolic rates were determined in 67 obese adolescents ranging in age from 10 to 16 years (30 male, 37 female). Basal oxygen uptake was determined on rising in the morning using open-circuit spirometry with a 10-min collection period. Body composition was determined from body density measurements using the underwater weighing procedure. There were no male-female differences (except for basal VCO2 production, P less than 0.05) for any body composition or metabolic variable. The subjects' (male and female) average weight was 73 kg, height--157 cm, percent fat--40 percent, fat weight--30 kg, lean body mass--92 kg, and kcal/24 h--1535. Correlations between age, body composition and basal energy expenditure were all moderate to low (r less than or equal to 0.78). In contrast to adult data, lean body mass was not highly correlated to basal energy expenditure suggesting that perhaps there is a 'metabolic condition' of the obese adolescent modulated by excess fatness or the instability of the body cell mass. Stepwise multiple linear regression revealed that for the obese male adolescent, body surface area and percent fat, and for the obese female adolescent body surface area and body weight resulted in the best prediction of basal kcal/24 h. The standard errors of prediction were +/- 17.9 percent for the males, and +/- 14.4 percent for the females.

The parasacral approach to the rectum

The posterior parasacral approach to the rectum is well-suited to several benign conditions and may occasionally be indicated in malignant rectal disorder. The York Mason modification of the Kraske procedure permits preservation of the sphincters and preservation of anal continence. The procedure is recommended as part of a surgeon's repertoire in operations on the rectum.

Validity of CO2-rebreathing cardiac output during rest and exercise in young adults

To validate the CO2-rebreathing method ( Defare 's method) for estimating cardiac output in children and young adults, measurements were compared to thermodilution ( TDCO ) cardiac output in 16 subjects (age 7-19 yr) with congenital heart disease. Data were collected at rest (N = 11) and during 4-min stages of supine bicycle exercise (N = 13). Estimated arterial-venous (-v-a)CO2 content differences related linearly to the measured CO2 content difference (Y = 0. 29X + 2.47, r = 0.65, P less than 0.001). With this (v-a)CO2 difference correction for all patients (N = 16), the correlation between CO2-rebreathing cardiac output and the TDCO was r = 0.87 (SEE = +/- 1.8 l X min-1). The correlation was higher for exercise (r = 0.81) than for rest (r = 0.65). We conclude that the CO2-rebreathing method, with a (v-a)CO2 content difference adjustment, is a simple, noninvasive technique providing estimates of cardiac output in children and young adults with congenital heart disease. Individual estimates should be treated with caution, especially when used for clinical evaluations.

Thermostable erythrocyte rosettes in chronic renal failure and allograft rejection

Rejection of an allograft usually is preceded by activation of T lymphocytes, in which state such cells may be identified by their ability to form thermostable rosettes with sheep erythrocytes (TE-R). The objective of the present work, therefore, was to determine whether or not enumeration of TE-R in the peripheral blood was of any value in the diagnosis of rejection. The results showed no significant differences between TE-R (mean +/- SEM) in normal subjects (9.9 +/- 1.3; n = 25), renal allograft recipients without rejections (13.5 +/- 1.7; n = 5) and in patients who suffered from acute tubular necrosis in the posttransplant period (12.4 +/- 2.5; n = 8). In contrast, recipients who had rejection episodes showed a marked rise in TE-R levels (43.0 +/- 4.0; n = 11) about two to seven days prior to the diagnosis of rejection by clinical and chemical criteria. Furthermore, TE-R remained high if the rejection episodes turned out to be irreversible after therapy (42.2 +/- 3.7) but fell if the episodes were reversible (19.9 +/- 3.2). TE-R values were elevated in patients with chronic renal failure on maintenance hemodialysis (45.7 +/- 4.9; n = 23). Neither acute dialytic runs or acute infections altered TE-R values. In conclusion, those results show that enumeration of TE-R may be helpful in the early diagnosis of allograft rejection, before clinical and chemical stigmata are apparent.

Extracranial carotid artery injury. Current surgical management

Fifty patients were treated for extracranial carotid artery trauma during the period from 1954 through 1981. The overall mortality rate was 20 percent. Primary repair was achieved in 38 patients (76 percent) with a mortality of 7.8 percent, and ligation was performed in six patients (12 percent) with a 50 percent mortality. The left carotid system was injured more frequently than the right; hemorrhage from an isolated carotid injury was readily controlled by digital pressure. Associated injuries affected the prognosis adversely. Significant neurologic deficits were present in 12 patients on first admission but the presence of neurologic deficit or coma did not serve as a contraindication to arterial repair and restoration of cerebrovascular continuity. Arteriography was not utilized once the clinical diagnosis of carotid arterial injury was made, but it was utilized when the proximity of the cervical injury provided the only suggestive evidence that vascular damage may have occurred. The presence of significant shock, coma, or neurologic deficit represent adverse prognostic features but do not contraindicate carotid repair. Profuse bleeding from a carotid injury or the presence of severe posthemorrhagic shock require urgent surgery. If control of bleeding is difficult to achieve, then ligation is preferred to suture repair.