Monosomy 21, partial duplication of chromosome 11, and structural abnormality of chromosome 1q21 in a case of lymphoma developing in a transplant recipient: characteristic abnormalities of secondary lymphoma?

Cytogenetic analysis by QFQ-banding of direct preparation of a testicular mass from a patient with secondary lymphoma revealed a modal chromosome number of 45,XY, including structural and numerical anomalies. The most consistent anomalies were the monosomy 21, duplication of the long arm of #11, and structural anomaly associated with chromosome #1 in band q21.

Quantitation of drug levels and platelet receptor blockade caused by a thromboxane antagonist

SQ 28,668 is a structural analog of thromboxane A2. It inhibits the effects of thromboxane in vitro. Fifty-six healthy male subjects were given either placebo or three equal daily doses of SQ 28,668 ranging from 25 to 1200 mg. Plasma drug concentrations increased in a dose-dependent manner. The shape of the plasma drug concentration-time curve was consistent with enterohepatic recirculation. The effects of SQ 28,668 on ex vivo platelet aggregation suggested that SQ 28,668 is a specific competitive antagonist of thromboxane A2 with a platelet receptor dissociation constant (estimated by Schild analysis) of about 19 nmol/L. Approximately 94% occupation of thromboxane receptors by SQ 28,668 was required to produce a small but measurable increase of the template bleeding time. Dose-ranging studies of antithrombotic drugs are difficult and expensive. For this reason, a method was developed that allows estimation of the dose of a thromboxane receptor antagonist that would be expected to be therapeutically equivalent to a given dose of aspirin.

Late results of the Mustard procedure in transposition of the great arteries

Thirty-five patients were discharged from the hospital after a Mustard procedure and have been followed a mean of 4.5 years. Thirty remain in a stable atrial or sinus rhythm, 3 have required hospitalization and medication to control atrial dysrhythmias, 1 is in a junctional rhythm, and 1 requires a pacemaker. In no patient has there been clinical evidence of systemic or pulmonary venous baffle obstruction. Twenty-two patients have had an elective postoperative cardiac catheterization, which has confirmed the absence of baffle obstruction. We attribute the lack of baffle obstruction and the low incidence of atrial dysrhythmias to several technical points in the operation including: direct high cannulation of the superior vena cava, aggressive resection of the atrial septum except in the region of the atrioventricular node, an extremely large pericardial baffle trimmed in the manner of Brom, sharp divergence of the upper and lower limbs of the inferior suture line away from one another and toward the caval orifices once they enter the right atrium, and very superficial endocardial bites of the baffle suture line in the region of the sinoatrial and atrioventricular nodes.

Treatment of hairy cell leukemia with recombinant alpha-interferon

Thirty patients with hairy cell leukemia were treated with recombinant interferon alpha-A (rIFN alpha A; Roferon-A); seven were previously untreated. Nine complete and 17 partial remissions were documented by bone marrow core biopsies. All patients' peripheral blood hematologic indexes either improved or normalized. Twelve of 13 patients with retroperitoneal or mediastinal adenopathy obtained remissions of tumor masses. All seven patients with splenomegaly showed prompt reduction in the size of the spleen to normal size. The incidence of complete remissions was significantly higher (P = .02) in previously untreated patients (5 of 7) than in those in whom splenectomy had been performed (4 of 23), a result presumed to be related to the pretreatment tumor burden. rIFN alpha A was well tolerated; mild fatigue was the most frequent complaint. In most patients, tumor remissions resulted in an improved quality of life: they eliminated the need for transfusing blood products and reduced the incidence of infections, and immune deficits were apparently restored in some of the patients. We conclude that rIFN alpha A is an effective therapy for all stages of hairy cell leukemia including previously untreated or newly diagnosed patients.

Bilateral phrenic nerve paralysis after the Mustard procedure. Experience with four cases and recommendations for management

Unilateral phrenic nerve injury is a recognized complication of thoracic operations, but bilateral diaphragmatic paralysis after an intracardiac procedure in an infant has not previously been described. In the past 10 years, four infants have sustained a bilateral phrenic nerve injury during the performance of a Mustard procedure. They were managed with tracheostomy and prolonged mechanical ventilation. Their recovery period ranged between 30 and 103 days and each had a satisfactory outcome. This technique was preferred to bilateral diaphragmatic plication because the results of that procedure have been equivocal. Tracheostomy reduced the catastrophic risk of an obstructed endotracheal tube, allowed immediate oral intake, and simplified the weaning process from the ventilator.

Early and late results of repair of partial anomalous pulmonary venous connection to the superior vena cava with a pericardial baffle

The early and late results of repair of partial anomalous pulmonary venous connection to the superior vena cava with a simple pericardial baffle without enlargement of the superior vena cava were examined. Fifteen consecutive patients received operations between 1973 and 1983, and all survived. They have been followed for a mean of 6 years and a minimum of 2 years. Nodal rhythm and atrial dysrhythmias were present in 6 patients (40%) early after operation. However, every patient resumed normal sinus rhythm prior to hospital discharge except 1 adult who remained in the preoperative rhythm of atrial flutter-fibrillation. No patient has clinical evidence of a residual atrial level shunt or superior vena cava obstruction. All have received an excellent clinical result, and none, except the patient in chronic atrial fibrillation, require cardiac medication. These results are comparable or superior to those obtained with more intricate procedures that use either complex atrial flaps or translocation of the superior vena cava to the atrial appendage.

The midterm and long-term results of the Mustard operation in patients with transposition of the great vessels and dynamic left ventricular outflow tract obstruction

Eight of 43 patients with transposition of the great vessels (TGV) and either an intact ventricular septum or very small ventricular septal defect were found to have dynamic left ventricular outflow tract obstruction (LVOTO). The preoperative left ventricle-pulmonary artery (LV-PA) pressure gradient ranged between 14 and 60 mm Hg. In 3 patients the pulmonary artery could not be catheterized. They had a left ventricular pressure of 43, 45, and 62 mm Hg, respectively, no evidence of pulmonary vascular disease, and either echocardiographic or angiocardiographic demonstration of LVOTO. The outflow tract was explored in 3 patients at the time of the Mustard operation. Exposure of the LVOT was difficult, particularly in patients less than 6 months of age. A shallow septal myectomy was performed in 1 patient; a thin fibrous endocardial scar was resected in 2; and no procedure was performed in the third. All 8 patients survived and remain asymptomatic 1 to 11 years (mean, 5 years) after operation. The LV-PA pressure gradient has either remained the same or has increased in every patient except 1 in whom there was a slight reduction in the gradient. We conclude that dynamic LVOTO persists after the Mustard operation and is not amenable to direct surgical relief. However, an excellent clinical result can be obtained for up to 11 years after operation.

Primary lymphoma of the mandible

The mandible is an uncommon presentation site for lymphoma and misdiagnosis is common. Eleven patients with lymphoma of the mandible were seen between 1947 and 1983. In 5 of the 11 patients, the diagnosis of lymphoma could not be established from the initial biopsy and additional material for examination was required. In three patients, this resulted in a partial or total removal of the mandible. In a recent histopathologic review, the diagnosis of diffuse large cell was made in seven, diffuse undifferentiated (non-Burkitt's) in two, diffuse undifferentiated (Burkitt's) in one, and unclassified in one. Using the Ann Arbor method of staging, six patients were determined to have stage IE disease; three had stage IIE, and two had stage IV. In 10 patients definitive treatment consisted of radiotherapy, chemotherapy, or a combination of both. Treatment was limited to surgery in one patient. The 5-year overall and disease-free survival rates were 62% and 50%, respectively. These results are comparable to those for lymphoma of other extranodal head and neck sites.

A Mr 90 000 surface polypeptide of Trypanosoma cruzi as a candidate for a Chagas' disease diagnostic antigen

Trypanosoma cruzi (Peru strain) trypomastigotes and epimastigotes were biosynthetically labeled with [35S]methionine, and the proteins were analyzed by two dimensional polyacrylamide gel electrophoresis (2D-PAGE). 2D-PAGE analysis of the trypomastigotes showed a complex array of polypeptides with distinct clusters at Mr 88 000-92 000, isoelectric point (pI) 5.6-6.0, and Mr 72 000-76 000, pI 5.6-5.8. 2D-PAGE analysis of the epimastigotes did not show the cluster of polypeptides at Mr 90 000. When the trypomastigote lysate was reacted with sera from either mice or humans chronically infected with T. cruzi, 10-50 polypeptides were immunoprecipitated. Five of these polypeptides were recognized by all sera tested. However, of these polypeptides, only three, two of Mr 90 000 and one of Mr 150 000, can be identified by immunoreaction of [35S]methionine-labeled live parasites as surface proteins of T. cruzi trypomastigotes. 125I-iminobiotinylated surface proteins isolated from T. cruzi trypomastigotes were immunoprecipitated with the same series of sera as described above. Chagasic sera immunoprecipitated an antigen of Mr 90 000. The [35S]methionine and 125I-labeled Mr 90 000 polypeptides were not immunoprecipitated with sera from individuals infected with Leishmania donovani, Leishmania braziliensis, Leishmania tropica or Leishmania mexicana. These data indicate that a surface polypeptide of Mr 90000, pI 5.8-5.9 is a viable candidate for a Chagas' disease diagnostic antigen.

Complete endocardial cushion defect: the late result of repair using the single-patch technique

Twenty-two patients have been followed for between 1 and 105 months after repair of a complete endocardial cushion defect. The mean period of follow-up is 3.5 years. The single-patch technique was used in every patient. The mitral valve was repaired with buttressed sutures in those seen more recently. The mean age at the time of operation was 15 months. Early in this experience, 4 patients had severe mitral valve incompetence after an initially satisfactory repair. In none of those patients had the mitral valve been repaired with pledgeted sutures. Two of those patients survived reoperation, and 2 died before a second operation could be performed. Every mitral valve is now repaired with pledgeted sutures, and there have been no failures of the mitral valve reconstruction. Each patient has been followed by the same pediatric cardiologist every 6 to 12 months after operation. The vast majority (17 of 20) are asymptomatic. Twelve have no mitral valve incompetence, and the remainder have only trivial or mild incompetence. Clinically, the pulmonary artery hypertension has resolved in 19 of 20 patients. Each patient remains in normal sinus rhythm. The long-term results following repair of complete endocardial cushion defect with the single-patch technique are excellent, but pledgeted sutures should be used in the mitral valve repair to insure its integrity.

Hypercalcemia, unusual bone lesions, and human T-cell leukemia-lymphoma virus in adult T-cell lymphoma

Extensive generalized and subperiosteal bone resorption was demonstrated in a patient with adult T-cell lymphoma and marked hypercalcemia of unclear pathogenesis. Antibody to the human T-cell leukemia-lymphoma virus (HTLV) was present in the serum of the patient, consistent with the recently reported association of adult T-cell lymphoma, hypercalcemia, and HTLV. The unique feature of this case was the presence of bone radiographic and pathologic findings consistent with hyperparathyroidism, in the absence of elevated parathormone levels. These findings contrast with the few previously reported cases of adult T-cell lymphoma with hypercalcemia, which showed lytic, sclerotic, or osteoporotic bone lesions. The authors suggest that the patient's malignant T-lymphocytes may have produced an osteoclast-activating-factor-like substance or a parathormone-like substance, which caused the striking bone changes. The exact role of HTLV in the pathogenesis of such cases remains to be determined.

The Hancock external valved conduit. A dichotomy between late clinical results and late cardiac catheterization findings

The Hancock external valved conduit was inserted in 18 children between 1974 and 1977. Seventeen patients survived operation and 15 are long-term survivors of 6 to 9 years. All patients have been closely followed up by the same pediatric cardiologist and each has undergone serial cardiac catheterization studies, generally performed at 1 and 6 years after operation. All long-term surviving patients have been in either New York Heart Association Class I or II. A few continue to take digoxin or diuretics. Cardiac catheterization demonstrated a gradient of 50 mm Hg or greater across the conduit in two of 16 patients 1 year after operation and in seven of 15 patients 6 years after operation. Five patients (30% of all long-term survivors) have had this conduit replaced and each has survived reoperation. The finding of a severe conduit gradient in one third of all long-term surviving patients is particularly bothersome since these patients were essentially asymptomatic. This study emphasizes the need for serial follow-up cardiac catheterization studies in all patients who receive the Hancock conduit.

Early intramedullary nailing of femoral shaft fractures: a cause of fat embolism syndrome

Results of our retrospective review of 100 consecutive patients show that early intramedullary nailing can be accomplished in severely injured patients without increasing the risk of fat embolism syndrome. No cases of fat embolism syndrome were seen after immediate (less than 24 hours) intramedullary nailing of femoral shaft fractures. In contrast, five cases of fat embolism syndrome were found in the patients treated in the traditional manner with initial balanced skeletal traction and delayed intramedullary nailing. There was a trend toward more pulmonary complications in the immediate group. This is attributed to the greater severity of injury present in the patients selected for immediate intramedullary nailing (injury severity scores 23.2 in immediate group; 12.4 in delayed group). The incidence of critical hypoxemia in the immediate group was equivalent to that in another group of injured patients who did not have fractures, but who did have similar injury severity scores.

Early closure of the patent ductus arteriosus in very low-birth-weight infants: a controlled trial

A controlled clinical trial comparing early closure (mean = 48.8 hours) of the patent ductus arteriosus using indomethacin to conventional medical management, with intervention only after cardiopulmonary decompensation (mean = 167.4 hours), was undertaken in 24 preterm infants with severe respiratory distress syndrome and evidence of PDA. An interval analysis of one-half the projected sample revealed that infants undergoing early closure of the PDA had significantly reduced occurrence of BPD or mortality by 6 months of age. A comparison of birth weight, Apgar scores, gestational age, age of initial PDA diagnosis, and fluid therapy during the first seven days of life showed no significant differences between early intervention and control groups. At the time of the interval analysis, there were no differences between the groups in duration of intermittent mandatory ventilation or oxygen exposure. Studies will be required to determine whether these and other variables can be altered by early closure of the PDA.

Mixed mesodermal tumors of urinary bladder: prognosis and management

Three cases of mixed mesodermal tumors of the urinary bladder characterized by the simultaneous occurrence of malignant epithelial and mesenchymal elements in the same tumor are reported. Integrated therapy consisting of preoperative radiotherapy followed by radical cystectomy is recommended. Chemotherapy is best withheld until the nature of any metastatic disease has been confirmed histologically in order that the appropriate drugs can be administered.

Strand-specific attachment of avidin-spheres to double-stranded poliovirus RNA

Poliovirus-specific double-stranded RNA molecules containing covalently attached protein were coupled with a biotin ester through the protein moiety. Subsequent interaction of the RNA-biotin with avidin attached to electronopaque plastic spheres led to the formation of complexes that were easily visualized in the electron microscope. Avidinspheres were associated only with one end of the RNA-biotin molecules, as seen in the electron microscope. Avidin-sphere attachment to poliovirus double-stranded RNA is strand specific, as shown by molecular hybridization of strand-specific probes to the separated strands of denatured complexes. [3H]DNA complementary to polio virion RNA hybridized exclusively to the strands bearing associated spheres [(+) strands] whereas 125I-labeled virion RNA hybridized predominantly with strands without spheres [(-)strands]. This biotin-avidin labeling technique provides a means for the isolation of full-length poliovirus (-) strands and may provide a general means for isolation of double-stranded polynucleotides containing tightly attached protein.

A collaborative study of infective endocarditis in the 1970s. Emphasis on infections in patients who have undergone cardiovascular surgery

Twenty-six major cardiovascular centers participated in a cooperative study of all cases of infective endocarditis occurring during a single calendar year to obtain an overview of infective endocarditis. The study was designed to learn which patients appear to be at highest risk to develop this infection after palliative or reparative cardiovascular surgery. Of 278 patients developing infective endocarditis during the year at these medical centers, 63 (23%) had had previous cardiovascular surgery and 215 had not. Seventy percent of the 278 patients had recognized congenital or acquired heart disease before developing the infection. Rheumatic heart disease accounted for over half of the patients with underlying structural heart disease. A majority (55%) of the 63 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of those who did not require prosthetic valves, the majority had congenital heart disease with systemic artery-to-pulmonary artery shunts. Although these data were obtained from a selected group of patients, they confirm a significant risk of endocarditis in patients with prosthetic valves and suggest that in postoperative patients with non-valvular congenital heart disease, the highest risk appears to be in cyanotic patients with palliative pulmonary artery-to-systemic artery shunts.

Current results with construction and interruption of the Waterston anastomosis

The Waterston anastomosis was constructed in 21 infants and neonates between 1973 and 1977. Sixteen neonates were 1 week old or less and 8 were less than 24 hours old. There were 2 operative deaths, giving a hospital survival of 90%. There were 3 late deaths. All surviving infants received satisfactory palliation except 1 who required a Potts anastomosis one year later. During the same time interval, 9 other patients who had had a Waterston anastomosis underwent complete intracardiac repair. Seven of them had significant angulation of the right pulmonary artery necessitating patch reconstruction. All patients survived operation, and follow-up pulmonary angiograms demonstrated only a slight persistent narrowing of the right pulmonary artery in 2 patients. We conclude that the Waterston anastomosis can be constructed with a low operative mortality even in the severely cyanotic neonate and that it can be taken down at the time of complete repair with minimal morbidity and no mortality even if it has significantly angulated the right pulmonary artery.