Carotid endarterectomy in the elderly

The records of 146 patients 80 years of age or older who underwent 183 carotid endarterectomy operations from 1964 through 1990 were reviewed to determine surgical risk. The indications for operation were asymptomatic patients with carotid stenosis (n = 36); ipsilateral transient ischemic attacks (n = 46); ipsilateral stroke (n = 28); ipsilateral retinal embolus (n = 15); nonlateralizing symptoms (n = 40); and asymptomatic side in patients with contralateral symptoms (n = 18). Postoperatively, three patients (1.6% of operations) had a stroke with a residual deficit and three (1.6%) died. All deaths were from myocardial infarction. For comparison, during the same time period, the combined stroke with residual deficit and death rate for patients less than 80 operated upon for similar indications was 3.5%. Since 80-year-old patients have a life expectancy of at least five years, the authors conclude that elderly patients should be evaluated for carotid endarterectomy using criteria similar to that used for younger patients.

Open-label study of the safety and efficacy of Fungoid tincture in patients with distal subungual onychomycosis of the toes

Onychomycosis is the most frequent cause of nail diseases. An open-label study has been conducted to evaluate the safety and efficacy of Fungoid Tincture, a topical antifungal agent approved by the Food and Drug Administration for the treatment of onychomycosis of the toes. Ten patients with culture-proven distal subungual onychomycosis were treated twice daily for twelve months with topical Fungoid Tincture. Another ten patients with the same condition were treated with the vehicle alone. At monthly intervals, the target nail was trimmed, the nail bed debrided, and global clinical assessment recorded. After twelve months of therapy, all patients applying Fungoid Tincture showed negative findings on fungal culture. The vehicle alone benefitted several patients, and may have antifungal activity. Adverse effects were minimal, with mild peeling occurring in seven patients and erythema noted in one.

Longitudinal pigmented nail bands

In this article, we have discussed the possible causes of a longitudinal pigmented nail band. A thorough history, physical examination, and, when indicated, biopsy of the origin of the band should reassure the patient with a benign lesion and direct further treatment of a patient with a malignant or potentially malignant lesion.

Retrospective cohort mortality study of workers at an aircraft maintenance facility. I. Epidemiological results

A retrospective cohort study of 14,457 workers at an aircraft maintenance facility was undertaken to evaluate mortality associated with exposures in their workplace. The purpose was to determine whether working with solvents, particularly trichloroethylene, posed any excess risk of mortality. The study group consisted of all civilian employees who worked for at least one year at Hill Air Force Base, Utah, between 1 January 1952 and 31 December 1956. Work histories were obtained from records at the National Personnel Records Centre, St. Louis, Missouri, and the cohort was followed up for ascertainment of vital state until 31 December 1982. Observed deaths among white people were compared with the expected number of deaths, based on the Utah white population, and adjusted for age, sex, and calendar period. Significant deficits occurred for mortality from all causes (SMR 92, 95% confidence interval (95% CI) 90-95), all malignant neoplasms (SMR 90, 95% CI 83-97), ischaemic heart disease (SMR 93, 95% CI 88-98), non-malignant respiratory disease (SMR 87, 95% CI 76-98), and accidents (SMR 61, 95% CI 52-70). Mortality was raised for multiple myeloma (MM) in white women (SMR 236, 95% CI 87-514), non-Hodgkin's lymphoma (NHL) in white women (SMR 212, 95% CI 102-390), and cancer of the biliary passages and liver in white men dying after 1980 (SMR 358, 95% CI 116-836). Detailed analysis of the 6929 employees occupationally exposed to trichloroethylene, the most widely used solvent at the base during the 1950s and 1960s, did not show any significant or persuasive association between several measures of exposure to trichloroethylene and any excess of cancer. Women employed in departments in which fabric cleaning and parachute repair operations were performed had more deaths than expected from MM and NHL. The inconsistent mortality patterns by sex, multiple and overlapping exposures, and small numbers made it difficult to ascribe these excesses to any particular substance. Hypothesis generating results are presented by a variety of exposures for causes of death not showing excesses in the overall cohort.

Nail disorders in children

The spectrum of nail abnormalities that may be seen in the pediatric population is discussed in this article. Developmental abnormalities, both hereditary and congenital, are discussed. Acquired nail abnormalities that may be similar to those seen in adults are also described.

Pharmacokinetics of cefotaxime and desacetylcefotaxime in patients with liver disease

The dispositions of cefotaxime and its metabolite desacetylcefotaxime were investigated in patients with different forms of chronic parenchymal liver disease (CPLD). A total of 31 subjects (27 patients and 4 controls) received a single 2-g dose of cefotaxime by infusion, and serial blood samples were drawn. The area under the concentration-time curve ranged from 176 to 241 micrograms.h/ml, the apparent half-life ranged from 1.49 to 2.42 h, and clearance ranged from 2.06 to 3.10 ml/min/kg in patients with four different forms of CPLD. The area under the concentration-time curve and the apparent half-life of desacetylcefotaxime ranged from 72 to 128 micrograms.h/ml and 7.1 to 13.4 h, respectively. Pharmacokinetic parameters were significantly different in patients with CPLD compared with those in control subjects and were related to clinical indices of hepatic impairment. Modest accumulation of cefotaxime in patients with severe hepatic impairment is unlikely to produce toxicity because of its high therapeutic index, and dosing modifications may not be required.

Late results of small untreated abdominal aortic aneurysms

We report our experience with 73 patients who were initially selected for nonoperative management of an abdominal aortic aneurysm less than 5 cm in diameter. Size of the aneurysm was determined by ultrasound (34); arteriography (16); computerized tomography (17); plain x-ray (4); and magnetic resonance imaging (2). End points of the study were subsequent elective resection, rupture, death from cause other than rupture, or an intact aneurysm followed for a minimum of three years. Overall, 28 (38%) aneurysms were subsequently resected on an elective basis; four (5%) ruptured; 15 (21%) were intact at the time of the patient's death; and 26 (36%) remained intact during follow-up of 3 to 6.5 years. Indications for elective resection were aneurysm enlargement (21); symptoms suggesting impending rupture (3); and improvement in medical condition (4). In the 43 aneurysms initially less than 4 cm diameter, 16 (37%) had elective resection and one (2%) ruptured, and in the 30 that were 4-4.9 cm, 12 (40%) were resected and three (10%) ruptured. The four aneurysms that ruptured had enlarged to greater than 5 cm prior to rupture. We conclude that aneurysms less than 4 cm can be safely followed. Aneurysms 4-4.9 cm should be considered for operation, depending upon the size of the aneurysm, patient's life expectancy, and risk factors for surgery. Any aneurysm that enlarges should be resected, especially if the aneurysm becomes larger than 5 cm in diameter.

Intrarectal sonography. A new technique for the assessment of rectal tumors

Preoperative staging of rectal tumors provides a selective therapeutic approach. Twenty-three patients were evaluated with prospective intrarectal sonography. Endosonography identified all 21 rectal lesions. Two patients with previous rectal carcinoma had no evidence of recurrence. Thirteen of 17 patients (76%) with rectal carcinoma were correctly staged by endosonography. A submucosal leiomyosarcoma and pararectal arachnoid cyst were correctly identified. Preoperative assessment of lymph node status was accurate in five of ten patients (50%). Results of preoperative digital rectal examination predicting rectal wall involvement correlated with pathologic findings in 11 of 15 patients (73%). Intrarectal sonography is an important staging technique for preoperative evaluation of rectal wall invasion and guides appropriate surgical intervention.

A novel membrane-bound glucosyltransferase from Bradyrhizobium japonicum

Bacteria within the family Rhizobiaceae are distinguished by their ability to infect higher plants. The cell envelope carbohydrates of these bacteria are believed to be involved in the plant infection process. One class of cell envelope carbohydrate, the cyclic beta-1,2-glucans, is synthesized by species within two genera of this family, Agrobacterium and Rhizobium. In contrast, species of the genus Bradyrhizobium, a third genus within this family, appear to lack the capacity for cyclic beta-1,2-glucan biosynthesis. Instead, these bacteria synthesize cyclic glucans containing beta-1,6 and beta-1,3 glycosidic linkages (K.J. Miller, R.S. Gore, R. Johnson, A.J. Benesi, and V.N. Reinhold, J. Bacteriol. 172:136-142, 1990). We now report the initial characterization of a novel membrane-bound glucosyltransferase activity from Bradyrhizobium japonicum USDA 110. Analysis of the product of this glucosyltransferase activity revealed the following: the presence of beta-1,3 and beta-1,6 glycosidic linkages, an average molecular weight of 2,100, and no detectable reducing terminal residues. The glucosyltransferase activity was found to have an apparent Km of 50 microM for for UDP-glucose, and activity was stimulated optimally by Mn2+ ions. On the basis of the structural properties of the in vitro glucan product, it is possible that this membrane-bound glucosyltransferase activity may be responsible for the biosynthesis of cyclic beta-1,6-beta-1,3-glucans by this organism.

Dobutamine digital echocardiography for detecting coronary artery disease

To assess the value of dobutamine echocardiography for detecting coronary artery disease (CAD), 70 men (mean age 62 +/- 8 years) presenting for coronary angiography were prospectively studied. Dobutamine (2.5 to 40 micrograms/kg/min) was infused in 3-minute stages. Digital echocardiograms were recorded on-line at baseline, during low- and high-dose dobutamine infusion, and at recovery. An echocardiogram positive for CAD was defined as one showing a new wall motion abnormality induced by dobutamine. Compared with coronary angiography, the overall sensitivity of dobutamine echocardiography for detecting CAD was 86%, specificity 95% and accuracy 89%. The sensitivity for detecting 3-vessel CAD was 100%, 89% for 2-vessel and 69% for 1-vessel CAD. The accuracy of predicting multivessel disease by 2 methods was 71% and 84%, respectively. Heart rate at the echocardiographic ischemic threshold was lower in patients with 3- and 2-vessel CAD versus 1-vessel CAD (89 +/- 17, 95 +/- 18 and 118 +/- 18 beats/min, respectively, p less than 0.01); rate-pressure product was also lower in patients with 3- and 2-vessel CAD versus 1-vessel CAD (12.7 +/- 3.6, 13.7 +/- 2.8 and 18.9 +/- 44 x 10(3) beats/min x mm Hg, respectively, p less than 0.01). Heart rate was the most important physiologic determinant of ischemia induced by dobutamine. There were no major complications during the study. Thus, dobutamine digital echocardiography is an excellent test for identifying CAD and should be beneficial in patients unable to exercise.

Nurses' attitudes, nurse-patient interactions and adherence to treatment by hemodialysis patients

Relationships among fluid intake and dietary-adherence of 29 hemodialysis patients, nurses' attitudes (liking-disliking) toward these patients, and selected nurses' and patients' verbalizations during hemodialysis treatment were explored. No significant associations were found. Nurses may be facilitating positive solutions to all patients' health care problems rather than admonishing those whom they dislike and/or who do not adhere to treatment.

Congenital malalignment of the great toenails

Congenital malalignment of the great toenails is a disorder in which malalignment of the nail matrix results in angular lateral nail plate growth. The consequence is onychodystrophy, which may progress to onychogryphosis and chronic ingrown toenails. There has been debate as to whether the condition is inherited or acquired in utero secondary to improper fetal positioning. A 6-year-old boy and his father, both of whom have this disorder, are discussed.

The diminishing role of diagnostic arteriography in carotid artery disease: duplex scanning as definitive preoperative study

In an effort to eliminate the inherent neurologic morbidity associated with arteriographic investigation, we have increasingly relied upon duplex scans of the extracranial carotid arteries prior to endarterectomy. The percentage of patients undergoing carotid endarterectomy without arteriograms has increased from 5% in 1984 to 69% during 1988-1989. Initially, carotid endarterectomy without arteriography was limited to patients with hemispheric symptoms and relative contraindications. Over the course of the study from 1984-1989, indications for operation were similar for patients having carotid endarterectomy on the basis of duplex scan alone or following arteriography. The perioperative outcome for these patients undergoing duplex scan (n = 255) and arteriography (n = 484) were similar for stroke (2.4%) versus 2.7%, p = NS) and death (0% versus 0.4%, p = NS). Stratification of groups by indication did not show any significant differences in outcome. Duplex scans were sufficiently accurate to replace preoperative arteriograms in identifying significant stenoses at the carotid bifurcation, including asymptomatic disease. Lack of information regarding intracranial arterial occlusive disease did not adversely affect perioperative outcome. Carotid arteriography can be used selectively when duplex scans are technically difficult, when physical examination or scans suggest either inflow (arch) disease or diffuse, distal internal carotid plaque, or when cerebral symptoms are not sufficiently explained by duplex findings.

Isolation of large numbers of enriched human megakaryocytes from liquid cultures of normal peripheral blood progenitor cells

Investigations linking human megakaryocyte development and cell biology have been hindered by an inability to obtain large, relatively pure megakaryocyte cell preparations from in vitro stem cell cultures. We report here that such preparations can be generated from liquid cultures of normal human peripheral blood mononuclear cells stimulated by a serum source of megakaryocyte colony stimulating activity (Meg-CSA, the 0% to 60% ammonium sulfate protein fraction of aplastic canine serum). Adherent-depleted peripheral blood mononuclear cells are suspended at 5 x 10(5) to 10(6) cells/mL in supplemented liquid culture medium, platelet-poor human plasma 20% (vol/vol) and 1 to 2 mg/mL serum Meg-CSA protein. After 12 to 14 days of incubation, megakaryocytes constitute 3.0 +/- 2.9% (mean +/- SD, n = 8) of the unseparated cultured cell population. Megakaryocytes can be enriched by counterflow centrifugal elutriation to a purity of 58 +/- 14% (+/- SD) with a recovery of 13 +/- 7% and a viability of 67 +/- 19%. This algorithm results in the average isolation of approximately 3 x 10(5) enriched megakaryocytes from a 100-mL starting volume of peripheral blood. Cultured megakaryocytes exhibit normal light and ultrastructural morphology by Wright-Giemsa staining and electron microscopic analysis. After a 12-day culture interval, enriched megakaryocyte preparations exhibit morphologic stage distributions that are similar to normal human marrow. Stage distributions move rightward with culture duration indicating partial synchrony of megakaryocyte maturation. On cytospin preparations, megakaryocyte diameter averages 30.2 +/- 1.5 microns and increases with maturation stage. Flow cytometric analyses demonstrate the expression of platelet glycoproteins (GP) Ib and IIb/IIIa by the cultured megakaryocytes. The modal ploidy of the enriched cells at day 12 of culture is 16N and most remaining megakaryocytes are 8N or 32N. Liquid culture of serum Meg-CSA-stimulated human peripheral blood mononuclear cells represents a valuable investigative tool that should permit studies of human megakaryocyte biology that have not been possible in the past.

The influence of neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).

Angioscopy for intraoperative management of thromboembolectomy

Our experience with angioscopy suggests that direct visualization of the arterial lumen during thromboembolectomy procedures would provide a more reliable method of assessing luminal morphologic characteristics than angiography alone. We inspected 32 grafts (seven aortobifemoral, 18 infrainguinal bypass, and seven dialysis access fistula grafts) in 32 patients. Thirty-one patients had thrombotic events and one patient had an acute embolus. Angioscopy following standard catheter thrombectomy revealed significant amounts of retained thrombus or neointima in all thrombectomies. Angioscopic information from 18 patients with an infrainguinal bypass graft led to graft revision in six cases and placement of a new graft in 10 cases. One graft limb was replaced in seven aortobifemoral grafts, and multiple repeated thrombectomies were employed to extract debris in the remaining six cases. Repeated graft thrombectomy was also beneficial in dialysis access fistulas. Angioscopy allowed us to omit the completion angiogram and led to an improved technical result. We conclude that angioscopy is useful during thromboembolectomy procedures.

The development of USP dissolution and drug release standards

Dissolution tests have been in use in the pharmaceutical industry for over 20 years, and they are official in The United States Pharmacopeia since the early 1960s. The dissolution test, reviewed primarily as a quality control tool, replaced the use of disintegration tests which had been official in The United States Pharmacopeia since 1950. Refinements in the dissolution test equipment and methodology have occurred over the years in order to enhance its relevance. The Subcommittees of the USP Committee of Revision dealing with these issues have developed and refined compendial dissolution standards and policies for conventional solid-oral dosage forms and modified-release dosage forms.

Human serum megakaryocyte colony-stimulating activity appears to be distinct from interleukin-3, granulocyte-macrophage colony-stimulating factor, and lymphocyte-conditioned medium

Sera from patients with bone marrow megakaryocyte aplasia are a rich source of megakaryocyte colony-stimulating activity (Meg-CSA). Other biologic materials exhibiting Meg-CSA include phytohemagglutinin-stimulated human lymphocyte-conditioned medium (PHA-LCM), recombinant interleukin-3 (IL-3), and recombinant granulocyte macrophage colony-stimulating factor (GM-CSF). Neutralizing antisera to both recombinant IL-3 and GM-CSF were used to evaluate the relationship among these sources of Meg-CSA. Varying dilutions of IL-3 and GM-CSF antisera were tested in plasma clot cultures of normal human peripheral blood megakaryocyte progenitors optimally stimulated by either IL-3 (1 U/mL), GM-CSF (1 U/mL), PHA-LCM (2.5% to 5% vol/vol), or aplastic human serum (10% vol/vol). IL-3 antiserum at dilutions up to 1/2,000 totally abrogated megakaryocyte colony growth stimulated by IL-3. A 1/500 dilution of GM-CSF antiserum completely eliminated GM-CSF-induced megakaryocyte colony development. A combination of anti-IL-3 and anti-GM-CSF, each at a 1/500 dilution, inhibited all megakaryocyte colony growth stimulated by optimal concentrations of IL-3 and GM-CSF together. There was no neutralizing crossreactivity between the IL-3 and GM-CSF antisera. At maximally neutralizing concentrations, IL-3 antiserum inhibited 66% of the megakaryocyte colony growth stimulated by PHA-LCM. Residual megakaryocyte colony growth was eliminated by the addition of a 1/500 dilution of anti-GM-CSF.(ABSTRACT TRUNCATED AT 250 WORDS)

The presence of a porphyropsin-based visual pigment in the juvenile lemon shark (Negaprion brevirostris)

The visual pigment from the juvenile lemon shark has been extracted and is a homogeneous vitamin A2-based porphyropsin with maximum absorption at 522 nm. This is the first report of a porphyropsin visual pigment extracted from the retina of an elasmobranch. In contrast, the visual pigment from the adult lemon shark yields a homogeneous vitamin A1-based rhodopsin with maximum absorption at 501 nm. We conclude that the porphyropsin of the juvenile lemon shark changes over to a rhodopsin as the animal matures.

The risk of carotid endarterectomy for the asymptomatic patient: an argument for prophylactic operation

We reviewed the records of 291 asymptomatic patients who underwent 377 carotid endarterectomy operations. The study excludes endarterectomies performed simultaneously with other operations that influence morbidity as well as endarterectomies on patients with symptoms caused by contralateral carotid stenosis. Postoperatively, nine patients had a stroke but two of the nine recovered completely after reoperation. Seven patients (2% of operations) were discharged with a neurologic deficit. One patient died of a myocardial infarction. Combined strokes with residual deficit and deaths totaled eight patients (2.2% of operations). During the time of the study the indication for operation changed from greater than 60% stenosis of the carotid artery to greater than 80% stenosis. This paper argues that, based on information currently available, a surgical morbidity rate of less than 3% justifies prophylactic endarterectomy. Surgeons must audit their results to demonstrate they can perform the operation with low risk to the patient.

Comparison of contrast arteriography to arterial mapping with color-flow duplex imaging in the lower extremities

Color flow duplex scanning was used to "map" the iliofemoral and femoral popliteal segments in 61 patients (84 extremities) undergoing evaluation for excimer laser angioplasty. Eight locations, iliac, common femoral, profunda femoris, proximal and distal superficial femoral artery, proximal and distal popliteal, and tibioperoneal trunk were scored as normal versus abnormal, greater than 50% stenosis, or occluded, and occlusions were measured in centimeters. Specificity, sensitivity, and accuracy were calculated with the arteriogram as the gold standard (83% and 96%, respectively, for normal vs abnormal, 87% and 99% for 50% stenosis, and 81% and 99% for occlusions). Color flow accurately identified the presence and extent of occlusions in 48 of 51 extremities (94%) when compared to arteriography plus operative findings, since arteriography alone tended to overestimate occlusion length. It is concluded that color flow Doppler alone may be used to screen patients with peripheral vascular disease to assess candidacy for endovascular procedures without antecedent arteriography, and that arteriography alone would exclude some patients from consideration by falsely overestimating occlusion lengths.

Rectovaginal fistula in Crohn's disease

Rectovaginal fistulas in the setting of Crohn's disease present a difficult management dilemma. Some patients with this problem require proctocolectomy, yet other patients with minimal symptoms never require an operation for treatment of the rectovaginal fistula. For a small percentage of patients, local surgical repair of the fistula may be warranted. Since 1980, this study has attempted local repair in seven patients with symptomatic rectovaginal fistulas from Crohn's disease. Five patients underwent staged repair of the fistula. Closure of the colostomy was eventually possible in three of these patients. Two of the three patients have had no evidence of recurrence at followup in excess of two years. The third patient required an ileostomy for intestinal disease and had no recurrence of the fistula. Two patients underwent primary repair of the rectovaginal fistula without fecal diversion; in one of these patients, the fistula recurred ten days after operation, necessitating a diverting ileostomy. The other patient remains cured 26 months after repair. The results of this review indicate that in the setting of quiescent rectal disease, an attempt to repair the fistula can be expected to have a reasonable chance of success. The presence of a rectovaginal fistula in a patient with Crohn's disease does not mandate removal of the rectum.

Monocular blindness after penetrating trauma to the carotid artery

Near-total or total blindness caused by chronic ocular ischemia is a well-recognized complication of severe atherosclerotic occlusive disease of the carotid artery (CA) but has not been previously reported in the English-language literature as a sequela of an occlusive CA injury. This report describes a patient who sustained a gunshot wound to the neck, which injured the ipsilateral internal CA, external CA, and vertebral artery. The location of the injuries precluded arterial repair. The patient was neurologically intact after operative exploration. Twenty months after the injury a marked loss of vision in the ipsilateral eye was detected. Chronic ocular ischemia was diagnosed from clinical findings and ophthalmoscopic examination results. Knowledge that chronic ocular ischemia and blindness can occur after an occlusive CA injury supports the use of primary arterial repair for all CA injuries. In those instances in which repair is not technically possible, frequent ophthalmoscopic examinations and testing of visual acuity should be used postoperatively to diagnose ocular ischemia; thus treatment to prevent the loss of sight can be carried out.