[Aspiration-induced lung complications following emergency endoscopy in upper gastrointestinal hemorrhage: incidence and localization by thoracic radiography]

PURPOSE

Determination of incidence and mortality of pulmonary pathologies arising after gastroscopy for acute bleeding, of left to right ratio of pulmonary findings in postgastroscopic chest films, and determination of a possible relationship between bleeding activity and frequency of aspiration.

METHODS

174 patients with emergency gastroscopies for upper gastrointestinal haemorrhage with pre-/postendoscopy chest films, retrospective analysis. Of the pulmonary findings, infiltrates and atelectases were considered.

RESULTS

After emergency gastroscopy, 16% of patients had infiltrates or atelectases at chest radiography. Mortality within 30 days in the study group was 18%, and 39% among the subgroup with radiologically proven pulmonary complications. The distribution of chest findings between left and right side was 1:1,3. In the subgroup with gastroscopic signs of bleeding the share of postgastroscopic pulmonary findings was slightly superior to that of patients without direct signs of bleeding; however, the difference was statistically not significant.

CONCLUSION

Endoscopy-related aspirations do not seem to account for an increased rate of pulmonary complications after emergency gastroscopy.

Comparative investigation of drug delivery of collagen implants saturated in antibiotic solutions and a sponge containing gentamicin

Collagen implants of various structures and a gelatine sponge were placed in five different antibiotic solutions until complete saturation occurred. The antibiotics were chosen to represent different drug classes (gentamicin sulphate, cefotaxim, fusidic acid, clindamycin, vancomycin). The collagen implants saturated with antibiotic solution and a lyophilized collagen sponge containing gentamicin sulphate were eluated in 0.066 M phosphate buffer (pH = 7.4) at 37 degrees C. The total eluation period is 7 d with buffer changes every 24 h. The antibiotic delivery by the collagen implants and the lyophilized sponge containing gentamicin sulphate is complete after a maximum of 4 d. If an implant that has a protective effect against wound infections over a period of 24-48 h is required, the materials described here are suitable. However, where treatment in infected areas should ensure antibiotic cover for 5-10 d, neither collagen materials immersed in antibiotic solutions nor collagen sponges containing gentamicin are suitable.

The quantitation of metabolites of quercetin flavonols in human urine

The flavonoid quercetin, or its metabolites, inhibit chemical carcinogenesis in rodents and may have a role in the prevention of human cancers. Quercetin exposure in human populations results from the dietary intake of various plant foods; high concentrations of quercetin are found in apples, onions, tea, and red wine. Determination of the relationship between dietary intake and cancer risk depends on the characterization of quercetin intake. The development and use of biomarkers for quercetin intake may provide a basis for the objective classification of this exposure. One possible biomarker is metabolic products of quercetin. We report the development of a high-performance liquid chromatography (HPLC)-based assay for quantitation of quercetin metabolites in human urine. The metabolites include 3,4-dihydroxyphenylacetic acid (homoprotocatechuic acid), metahydroxyphenylacetic acid, and 4-hydroxy-3-methoxyphenylacetic acid (homovanillic acid). The assay has only two major steps, ether extraction and HPLC analysis, and is suitable for analysis of large sample numbers. Analytical characteristics of the assay include a sensitivity of less than 1 microgram, precision with coefficients of variation < 10%, and metabolite recoveries > 90%. The mean concentrations of 3,4-dihydroxyphenylacetic acid, metahydroxyphenylacetic acid, and homovanillic acid in two human urine samples are approximately 0.7, 4.8, and 2.8 micrograms/ml, respectively. The identification of each metabolite is confirmed by HPLC, UV absorbance scans, and gas chromatography-mass spectrometry analysis. These results verify the occurrence of quercetin metabolites in human urine and the feasibility of quercetin metabolite quantitation, by the assay described herein, for epidemiological studies. Development of the analytical procedure is an essential first step for validation of the metabolites as biomarkers of quercetin intake.

Family burden of schizophrenia and bipolar disorder: perceptions of relatives and professionals

OBJECTIVE

The study compared the burden that specific problem behaviors of patients with schizophrenia or bipolar disorder placed on relatives and evaluated the accuracy of mental health professionals' judgment of the burden.

METHODS

A questionnaire was developed to assess the burden of 20 common problem behaviors associated with manic, positive, and negative symptoms. The questionnaire was given to 48 relatives of patients with schizophrenia or bipolar disorder. In addition, 39 mental health professionals completed separate questionnaires indicating the amount of burden they believed relatives experienced due to these behaviors.

RESULTS

Relatives of patients with bipolar disorder rated manic symptoms as more burdensome than did relatives of patients with schizophrenia, but relatives of patients in the two groups did not differ in their ratings of burden associated with positive or negative symptoms. Professionals' perceptions of the burden associated with manic symptoms were relatively accurate, but they tended to underestimate the burden of positive and negative symptoms experienced by relative of patients with bipolar disorder.

CONCLUSIONS

Psychiatric diagnosis may be of limited value in understanding the burden relatives experience due to specific psychiatric symptoms. Professionals are encouraged to assess the burden that is associated with specific problem behaviors regardless of psychiatric diagnosis.

Effect of specimen fixation method on pullout tests of pedicle screws

STUDY DESIGN

Experimental axial pullout tests of a new type of pedicle screw were done on cadaveric lumbar vertebrae. The manner in which specimens were secured in the testing apparatus was varied to determined influence of specimen fixation method on the maximum pedicle screw pullout force.

OBJECTIVES

To determine the appropriateness of embedding (i.e., potting) spinal specimens in polymer resin (e.g., bone cement or Plastic Padding [Plastic Padding Ltd., High Wycombe, Buckinghamshire, England]) for axial pullout tests of pedicle screws. Several different specimen fixation methods were examined to make recommendations for the standardization of future experimental testing protocols.

SUMMARY OF BACKGROUND DATA

Axial pullout of transpedicular screws, although not a likely clinical mode of failure, is a popular experimental testing mode for evaluating screw-bone biomechanics. A wide variety of techniques for securing a vertebral specimen to counter the axial pullout force has been reported (including the use of polymer resin) with a correspondingly wide range in the resulting axial pullout strengths. The possible influence of the specimen fixation method on pedicle screw axial pullout strength has not been addressed previously.

METHODS

Axial pullout tests of pedicle screws (DDS, Plus Endoprothetik, Rotkreuz, Switzerland) from the pedicles of 21 isolated lumber vertebral bodies were done using a Model 810 MTS Universal Testing Machine (MTS Systems, Inc., Minneapolis, Minnesota). The specimens were secured in a custom-made vise fixture either as is or after the vertebral bodies were potted in Plastic Padding up to the pedicle origin. Some of the potted specimens were wrapped first in latex to prevent polymer resin intrusion, and the others were unprotected. Pullout tests were attempted on both the left and right pedicles of each specimen, and the maximum pedicle screw pullout force was recorded. Measurement of bone mineral density by means of dual energy x-ray absorptiometry, in addition to macroscopic and scanning electron microscopy histologic analyses, microradiography, and energy dispersive X-ray spectroscopy, was done post-test to assist in the interpretation of the data.

RESULTS

The maximum pedicle screw pullout force was found to be dependent on both the bone mineral density and the mode of fixation of the vertebrae. Embedding in polymer resin without protection of the specimen (i.e., latex wrapping) led to several instances of well-documented polymer resin intrusion; in these specimens, mean maximum pedicle screw pullout force was significantly greater than that of specimens secured without polymer resin and that of embedded specimens for which intrusion did not occur.

CONCLUSIONS

Polymer resin intrusion can have a significant effect on the biomechanical characteristics of the bone-pedicle screw interface. When polymer resins are used to secure vertebral specimens for in vitro biomechanical tests of the bone-pedicle screw interface, it is important to either prevent intrusion (e.g., with a latex wrapping) or document post-test (e.g., through the methods described in this article) that intrusion did not occur for the specimens included in the analysis.

[Chemoembolization in primary liver cell carcinoma. Results of a prospective study]

A remarkable progress was made in the palliative treatment of unresectable hepatocellular carcinoma using transcatheter arterial chemoembolization (TAC). The combination of doxorubicin as cytotoxic drug and of Lipiodol as carrier, which is selectively accumulated within the tumors is an effective treatment. Prolonged survival has been demonstrated in several clinical studies. In a prospective trial the effect of regional TAC with temporary ischemia of the liver was evaluated concerning liver function, systemic reactions and tumor response. Temporary ischemia of the liver was well tolerated even in patients with liver cirrhosis. Revascularization of the liver after TAC was observed in all cases. Systemic side effects of the cytotoxic drug were mild. In patients with Child C cirrhosis or tumor volume of more than 60% of the liver no impact of the treatment on the survival time was observed. In the entire patient group a survival rate of 70% after 15 months was achieved.

Stimulation of protein phosphatases as a mechanism of the muscarinic-receptor-mediated inhibition of cardiac L-type Ca2+ channels

Acetylcholine decreases currents through cardiac L-type Ca2+ channels after stimulation with agents which elevate levels of cyclic adenosine monophosphate, such as isoproterenol, but there is still a controversy over the mechanisms of this muscarinic effect. We tested the hypothesis of whether, after isoproterenol stimulation, protein phosphatases are activated by acetylcholine. Whole-cell currents were recorded from guinea-pig ventricular myocytes. The effect of 10(-5) M acetylcholine on currents induced by 10(-8) M isoproterenol was studied in the absence or presence of protein phosphatase inhibitors. Three agents reduced the acetylcholine response: okadaic acid (3 or 9 x 10(-6) M) and cantharidin (3 x 10(-6) M) added to the pipette solution, and bath-applied fluoride (3 mM). In contrast, pipette application of other phosphatase inhibitors, namely the inhibitor PPI2 (1000 U/ml), ciclosporin (10(-5) M), or calyculin A (10(-6) M) did not significantly diminish the acetylcholine effect. Interestingly, there was no correlation between the effects of the compounds on basal Ca2+ current and their interference with the muscarinic response. An activation of type 2A phosphatases by acetylcholine would explain these findings. Indeed, okadaic acid is 3 orders of magnitude more potent in vitro in its inhibition of this isoform (purified from cardiac myocytes) than is calyculin A, while type-1 phosphatases are inhibited equally. The data support the attractive possibility that stimulation of protein phosphatases is part of the signal transduction cascade of Ca2+ channel inhibition by acetylcholine.

An all sulfur analogue of the smallest subunit of F420-non-reducing hydrogenase from Methanococcus voltae--metal binding and structure

The 25 amino acid long subunit VhuU of the F420-non-reducing hydrogenase from Methanococcus voltae contains selenocysteine within the consensus sequence of known [NiFe] hydrogenases DP(C or U)CxxCxxH (U = selenocysteine). The sulfur-analogue VhuUc was chemically synthesized, purified and its metal binding capability, the catalytic properties, and structural features were investigated. The polypeptide was able to bind nickel, but did not catalyse the heterolytic activation of H2. 2D-NMR spectroscopy revealed an alpha-helical secondary structure for the 15 N-terminal amino acids in 50% TFE. Nickel only binds to the C-terminus, which contains the conserved amino acid motif. Structures derived from the NMR data are compatible with the participation of both sulfur atoms from the conserved cysteine residues in a metal ion binding. Structures obtained from the data sets for Ni.VhuUc as well as Zn.VhuUc showed no further ligands. The informational value for Ni.VhuUc was low due to paramagnetism.

Experience with the Novacor left ventricular assist system as a bridge to cardiac transplantation, including the new wearable system

The three components of the Novacor left ventricular assist system, compact controller, battery, and back-up battery, have been miniaturized in the development of the wearable system. Therefore patients can be fully mobilized receiving mechanical circulatory support while awaiting heart transplantation. Between February 1992 and April 1994 a total of eight patients with decompensated heart failure (6 dilated cardiomyopathy, 1 acute myocarditis, 1 ischemic cardiomyopathy) were treated with the Novacor left ventricular assist systems. In the most recent four cases the wearable system (N100P) was used. Patients' ages ranged from 17 to 49 years. In five patients severe failure of the right side of the heart was present at the time of implantation. Hemodynamic stabilization was achieved in all patients during the 2 to 122 days (mean 30.8 +/- 42.5 days) of support. The following parameters were measured on average before and 24 hours after implantation of the left ventricular assist system: mean arterial pressure 70 +/- 11 versus 87 +/- 13 mm Hg (p < 0.05), cardiac index 1.71 +/- 0.42 versus 3.23 +/- 0.74 L/min/m2 (p < 0.05), pulmonary capillary wedge pressure 27.1 +/- 4.4 versus 9.9 +/- 5.2 mm Hg (p < 0.01), mean pulmonary pressure 41 +/- 9 versus 27 +/- 6 mm Hg (p < 0.05), and right ventricular ejection fraction 16.7% +/- 10.3% versus 22.0% +/- 11.6% (not significant). Patients who received the wearable system were capable of managing their own power supply during the bridging period and were able to walk to the hospital park and shopping area. One patient had a serious pulmonary infection, which was treated successfully, and two patients had a cerebrovascular accident, which resolved in one and resulted in a minor residual deficit in the other. All eight patients received a heart transplant. One patient died early after transplantation and seven patients are alive and well. In summary, the wearable Novacor left ventricular assist system provides major advantages regarding quality of life of patients during mechanical circulatory support. However, there is a remaining risk of thromboembolism despite anticoagulation therapy.

Medical malpractice reform as a part of health care reform

It appears that any health care reform will include tort reform. Since health care reform is aimed at reducing the cost of providing health care and since medical malpractice is believed to be a significant portion of that cost, any health care reform bill passed under the current political climate will most likely include provisions for limiting the costs associated with medical malpractice.

Reduction of cyclosporine-induced nephrotoxicity by cilastatin following clinical heart transplantation

The objective of this prospective, randomized, placebo-controlled, single-blinded study in 28 heart-transplanted patients was to investigate whether the dehydropeptidase inhibitor cilastatin reduces cyclosporine-induced nephrotoxicity. Cilastatin is available only in combination with imipenem, a beta-lactam antibiotic to which it is added for reduction of nephrotoxic side-effects of the antimicrobial agent. Patients received either 100 ml placebo (n = 12) or 100 ml (500 mg) imipenem/cilastatin (n = 16) twice perioperatively, and 4 times daily for the first 7 postoperative days. Serum creatinine and urea, as well as urine concentrations of N-acetyl-beta-D-glucosaminidase, which is directly correlated with tubular cell damage, were used as markers for renal function. Thromboxane B2 and 6-keto-prostaglandin F1-alpha serum concentrations were determined to investigate whether there is an imbalance in synthesis of thromboxane A2 and prostacyclin as a possible mechanism for cyclosporine-induced nephrotoxicity. Two placebo patients and 6 patients receiving imipenem/cilastatin had to be excluded from further analysis. Three of 10 placebo patients required hemofiltration, and 2 of them even required hemodialysis, as compared with none in the imipenem/cilastatin group. Creatinine concentrations increased significantly from the second to the fourth postoperative day in the placebo group, but remained nearly normal in cilastatin patients (P < 0.05 for intergroup comparison on postoperative days 2-4). The same trend was observed in urea and N-acetyl-beta-D-glucosaminidase concentrations, without the difference reaching statistical significance. For thromboxane B2 and 6-keto-prostaglandin F1-alpha no differences between the groups could be found. These results suggest that imipenem/cilastatin can counteract acute cyclosporine-induced nephrotoxicity, which appears to be associated with alterations of tubular cell function. The combined use of cyclosporine and imipenem/cilastatin appears to be advantageous in patients following heart transplantation during the initial postoperative period.

Degeneration model of the porcine lumbar motion segment: effects of various intradiscal procedures

In an experimental study with 18 minipigs, we have tried to establish a model for the standardized evaluation of mechanical, histological and radiological phenomena of degenerative and reparative processes within the lumbar motion segment. Comparing different operative techniques revealed that the intradiscal application of hyaluronic acid into the nuclear defect is likely to enhance the regeneration process. Using the measurement of disc compliance, a semiautomatic picture analyzer and a new semiquantitative disc score could make future studies more comparable. From this basis, the intradiscal application of hyaluronic acid deserves further evaluation.