Cervical hyperostosis: a rare cause of dysphagia. Case description and bibliographical survey

Dysphagia can be caused by disorders of the cervical spine. Very seldomly, prominent osteophytes of the ventral spine are responsible. The case of a 63-year-old patient with large anterior osteophytes from C3 to C7 is presented. The successful ablation of these spondylophytes relieved the patient of his swallowing difficulties. Up to now there have been many different opinions about the etiology of this disease. In this special case, a diffuse idiopathic skeletal hyperostosis, also known as Forestier's disease or diffuse idiopathic skeletal hyperostosis, seems to be the most likely cause.

[Porphyria cutanea tarda, chronic liver disease caused by the C virus and hepatocarcinoma. Clinical case]

We report a non alcoholic, Chinese, 65 years old male that presented in august, 1992 with painful hepatomegaly of rapid installation and malaise. Ultrasound examination revealed multiple substitution images, diagnosed histologically as hepatoma. Serum alpha fetoprotein was 6600 U/ml. Malaise increased and the patient died two months later. This patient had a porphyria cutanea tarda and a chronic hepatitis diagnosed 6 years before. He also had positive titers for hepatitis C virus antibodies. In patients with porphyria cutanea tarda, hepatoma frequency is 400 fold higher and hepatitis C virus infection is highly prevalent. Thus, the surveillance of these patients with periodic alpha feto protein determinations and abdominal ultrasound examinations is recommended, specially in those infected by hepatitis C virus.

[Reversibility of early stage diabetic nephropathy]

A double blind crossover trial was performed on the effect of enalapril on urinary albumin excretion (UAE) in normotensive insulin dependent diabetics. Nineteen normoalbuminuric (UAE < 30 mg/24 h) and 17 microalbuminuric patients (UAE > 30 and < 300 mg/4 h) were studied; all patients had post prandial blood glucose levels < 180 mg/dl, HbA1 < 11% and none had chronic diabetic complications. Both groups had similar age, years of diabetes, body mass index and protein ingestion (70 g/day). Fifty percent of patients in each group received 5 mg/day of enalapril or placebo during one year, and during the second year the therapy was switched. No changes were observed in blood pressure, post prandial blood glucose, HbA1 and plasma electrolytes during the study period. A reduction in creatinine clearance, within normal limits, in both groups of patients treated with enalapril and no modifications with placebo were observed. UAE decreased significantly in normo and microalbuminuric patients initially treated with enalapril from 19 +/- 8 to 8 +/- 2 and from 71 +/- 19 to 39 +/- 12 mg/24 h respectively. These values increased during the placebo period to 23 +/- 6 and 47 +/- 13 mg/24 h respectively. Among those initially treated with placebo, UAE increased only in normoalbuminurics from 19 +/- 7 to 28 +/- 9 mg/24 h. During subsequent treatment with enalapril, UAE decreased in both groups. It is concluded that, in this group of patients, enalapril decreases UAE, possibly preventing the progression to severe forms of diabetic nephropathy.

Septic shock: does adrenaline have a role as a first-line inotropic agent?

Fifteen adult patients, admitted to Baragwanath Hospital ICU with septic shock after adequate fluid loading and on no other inotropic agents, were given adrenaline in incremental doses. Oxygen transport and haemodynamic variables were monitored with each dose increment until a systolic blood pressure of 120 mmHg was obtained. This was reached on an average dose of adrenaline of 0.16 +/- 0.02 micrograms/kg/min. Mean arterial blood pressure increased by 22 +/- 2 mmHg mainly due to an increase in cardiac index (1 +/- 0.2 l/min/m2) and systemic vascular resistance index (130 +/- 41 dyn.s.cm.-5m-2) with a small increase in heart rate of 8 +/- 3 beats per minute. Oxygen delivery was increased with no significant increase in oxygen consumption and lactate levels increased. Adrenaline is therefore an effective initial inotropic agent. Patients may respond to lower doses than when used concurrently with other inotropic agents but there was still a significant dose variation in response. We cannot, however, exclude a deleterious effect on oxygen utilization.

[Granulomatous vasculitis--an uncommon manifestation of herpes simplex infection of the central nervous system]

A man died at the age of 50 years, following tentative clinical diagnosis of centrotemporal brain tumour. Strongly pronounced, extended, partially necrotized haemorrhagic inflammation of the leptomeninx, considerably thickened and reaching into cerebral tissue above, was recorded from the cerebral basis on post-mortem examination. The spinal leptomeninx was involved in the inflammatory process. Severe exudative and primary productive pseudotuberculous inflammation was the histological finding, although tuberculous origin could not be confirmed by bacteriological culturing. Polymerase chain reaction with subsequent southern-blot hybridization revealed Herpes simplex virus Type I as the cause of inflammation.

Prevention of transfusion-associated cytomegalovirus infection in neonatal patients by the removal of white cells from blood

The usual methods employed to reduce the risk of transfusion-associated cytomegalovirus (TA CMV) disease have been to transfuse blood or cellular blood components that are CMV antibody-negative or to administer deglycerolized frozen red cells. To determine if the reduction of white cells (WBCs) in blood by filtration will also eliminate TA CMV disease in a high-risk population, 48 surviving very low birth weight (less than 1250 g) neonatal infants born to CMV-seronegative mothers at three participating institutions in the Hartford, Connecticut area and receiving at least one CMV-seropositive blood transfusion were studied. The incidence of TA CMV disease in 26 neonatal patients who received blood prepared by a modified spin-cool-filter technique and in 22 neonatal patients who received blood filtered through a WBC-reduction filter was compared with the incidence of transfusion-associated disease in similar populations reported in other studies. The CMV antibody prevalence of the blood donor population was found to be 37 percent. At the time of discharge of the individual neonatal infants in the population studied, and/or 2 to 6 months later, 47 of the 48 who had undergone transfusion had CMV antibody-negative serologic tests and/or urine culture. The other infant transiently seroconverted because of passive transfer of the antibody. None of the 48 neonatal infants had clinical evidence of CMV infection. This study indicates that WBC reduction of donor blood can reduce and perhaps prevent TA CMV disease in high-risk neonatal patients.

[The hepatic porphyrias: experience with 105 cases]

Hepatic porphyria is a rare metabolic syndrome caused by abnormal enzyme activity in heme biosynthesis. Between 1974 and 1991; 105 patients have met criteria for diagnosis of hepatic porphyria based on typical clinical findings and/or laboratory abnormalities. According to type, 42% had porphyria cutanea tarda, 21% porphyria variegate, 15% protoporphyria, 6.7% acute intermittent porphyria, 6.7% coproporphyria and 1.9% porphyria due to porphobilinogen deficit. A proper classification was not established in 6.7% of patients. Porphyria cutanea tarda was more common in males (70%) and porphyria variegata, in females (90%). A family history of the disease was present in 33% of patients; 20% of patients were of European descent and 4% of Mapuche descent. Diagnosis was usually established in the third decade, somewhat later in porphyria cutanea tarda (45 years of age) and very early in protoporphyria. 10% of patients were asymptomatic and 29 patients developed at least one porphyric crisis. These were related to pregnancy in 6 patients, to hormone administration in 7, to antibiotics in 5. No cause was established in 21 cases. Severe crisis were successfully treated with Hematin. Venipuncture was used to treat 50% of patients with porphyria cutanea tarda with 95% success. Thus, hepatic porphyria is recognized with increasing frequency and can be treated successfully in most cases.

Cytomegalovirus antibody detection in blood donors and mothers of very low birth weight neonates by using three serologic methods

We compared three serologic methods for cytomegalovirus (CMV) antibody detection and determined the CMV antibody seroprevalence of blood donors and mothers of very low birth weight (less than 1250 g) neonates in the Greater Hartford region. CMV serology was determined for 577 healthy blood donors as well as for 147 mothers of premature infants. Plasma from blood donors and sera from mothers were tested by either latex agglutination (LA) or by an immunofluorescent antibody assay (IFA), and results were compared with those from an enzyme-linked immunosorbent assay (ELISA). Sensitivity and specificity for LA to ELISA were significantly better than for IFA to ELISA [sensitivity 79/81 (97%) vs 171/202 (85%), and specificity 90/94 (96%) vs 257/347 (74%), p less than 0.01]. These differences remained whether plasma or sera were tested. Borderline values explained only two (33%) of six LA-ELISA as well as only 70 (58%) of 121 IFA-ELISA discordance. CMV seroprevalence rate for the donor blood population was 38%, and for the mothers was 53%. The LA assay is superior to the IFA assay for CMV screening of blood donors and maternal populations.

Comprehensive predictions of outcome in closed head-injured patients. The development of prognostic equations

A comprehensive diagnostic evaluation was administered to 162 closed head-injured patients within 1 to 21 days (mean, 7.5 days) after injury. Each evaluation consisted of (1) power spectral analyses of electroencephalogram (EEG) recorded from 19 scalp locations referenced to age-matched norms, (2) brainstem auditory evoked potentials, (3) computed tomography (CT)-scan, and (4) Glasgow Coma Score (GCS) at time of admission (GCS-A) and at time of EEG test (GCS-T). Functional outcome at one year following injury was assessed using the Rappaport Disability Rating Scale (DRS), which measures the level of disability in the six diagnostic categories of (1) eye opening, (2) best verbal response, (3) best motor response, (4) self-care ability for feeding, grooming, and toileting, (5) level of cognitive functioning, and (6) employability. The ability of the different diagnostic measures to predict outcome at one year following injury was assessed using stepwise discriminant analyses to identify patients in the extreme outcome categories of complete recovery versus death and multivariate regression analyses to predict patients with intermediate outcome scores. The best combination of predictor variables was EEG and GCS-T, which accounted for 74.6% of the variance in the multivariate regression analysis of intermediate outcome scores and 95.8% discriminant accuracy between good outcome and death. The best single predictors of outcome in both the discriminant analyses and the regression analyses were EEG coherence and phase. A gradient of prognostic strength of diagnostic measures was EEG phase greater than EEG coherence greater than GCS-T greater than CT-scan greater than EEG relative power. The value of EEG coherence and phase in the assessment of diffuse axonal injury was discussed.

[Microalbuminuria in insulin-dependent diabetics: the prevention of diabetic nephropathy]

We evaluated the effects of angiotensin converting enzyme inhibition upon the urinary excretion of albumin in 36 insulin dependent normotensive diabetic patients with adequate metabolic control and no evidence of renal failure. 19 subjects had normal levels of albumin excretion (< 30 mg/24 h) and 17 showed microalbuminuria from 30 to 300 mg/24 h. Half of the patients were randomly selected in each group to receive enalapril, 5 mg/day. A progressive decrease in albumin excretion levels was observed for both enalapril treated subgroups, from 18.9 +/- 8.3 to 8.1 +/- 2.7 mg/24 h (normoalbuminurics) and from 73.1 +/- 25.0 to 40.1 +/- 26.3 mg/24 h (microalbuminurics). In contrast, an increase in albumin excretion from 19.4 +/- 6.8 to 29.4 +/- 14.2 mg/24 h was observed in non treated normoalbuminuric patients. Untreated patients with microalbuminuria remained with stable albumin excretion levels (67.4 +/- 39 to 64.8 +/- 23.4 mg/24 h). Enalapril treatment was associated to a significant (p < 0.05) decrease in creatinine clearance which remained within normal limits. Blood pressure, Na and K plasma levels and total proteins remained normal throughout the study. Thus, angiotensin converting enzyme inhibition reduces the urinary excretion of albumin in insulin dependent diabetics with normo or microalbuminuria.

[Morphometric approach to the assessment of the heel bone in the computed tomogram]

Computed tomography of the hindfoot is a well established examination, particularly in traumatology (1, 7, 9, 13, 14, 17). A simple measurement to estimate the shape of the os calcis in CT is presented. On a number of normal feet standard values were determined. The principle can be used in pathologic cases as well and deformity can be quantified. A neutral rating of post-therapeutic results is possible. The method can be performed easily and rapidly and is therefore suitable for routine practice.

Pentoxifylline-induced modulation of human leukocyte function in vitro

We previously demonstrated that pentoxifylline stimulated leukocyte migration in vitro and leukocyte accumulation in vivo and protects neonatal mice from experimentally induced Staphylococcus aureus infections. In the present studies we have investigated pentoxifylline's effect on human leukocyte function in vitro. In these studies we demonstrate that pentoxifylline at low concentrations (ie, 0.01 and 0.1 mg/ml) stimulates both leukocyte migration and microbicidal activity in vitro. Alternatively, low concentrations (0.001 to 0.1 mg/ml) of pentoxifylline had no significant effect on the binding uptake of S. aureus by leukocytes, nor did it enhance phagocytic degranulation. At extremely low concentrations (0.001 mg/ml), pentoxifylline enhanced oxygen metabolism by human leukocytes, as reflected by increased H2O2 production and chemiluminescence (CL). At higher concentrations (ie, 0.1 to 1 mg/ml), pentoxifylline consistently suppressed these leukocyte functions in vitro. Thus, this study supports the following hypothesis: 1) the in vivo effects of pentoxifylline may involve a direct effect on both leukocyte mobilization and microbicidal activity, and 2) the enhanced microbicidal activity induced by pentoxifylline may be a result of enhanced leukocyte oxygen metabolism. In summary, pentoxifylline appears to be an interesting immunomodulator (ie, immunoenhancement and immunosuppression) of leukocyte function in vitro, but additional studies will be required before the efficacy of pentoxifylline in man can be determined.

[Arthrocele of the knee joint--a differential diagnosis to deep venous thrombosis]

The symptoms of a thrombosis in deep veins of the calf in patients with rheumatoid arthritis should have thought of the possibility of a synovial cyst or synovial cyst rupture. Because of their too small specificity clinical findings do not allow to decide for one of the two diagnosis. Phlebography and/or arthrography effect the clarification which is necessary for an effective therapy with low risk. Arthrosonography gets increasing importance instead of arthrography.

[Toxicity of different endodontic antiseptics]

The median lethal dose (LD 50) of endodontic antiseptics sodium hypochlorite, chloramine and chlorhexidine digluconate was determined in experiment on albino mice using the method described by Litchfield and Wilcoxon. Sodium hypochlorite and chloramine have shown a twice stronger toxic effect than chlorhexidine digluconate. The difference was significant.

[Antimicrobial effect of endodontic antiseptics]

The endodontic antiseptics chloramine, sodium hypochlorite and chlorhexidine digluconate were evaluated for antimicrobial effect by a complex of susceptibility testing. In the agar diffusion test, tube dilution test and plate flooding test chlorhexidine digluconate was the most efficient agent against isolates of infected root canal.

[Prospective study of the late sequelae of electroconvulsive treatment]

In a prospective pilot study 1-3 years after no less than 5 ECT. 12 patients were examined clinically, and by means of psychological tests and computer-aided tomography. Convincing indications of lasting therapy-determined brain damages could not be found.

[Effect of physical training on the aerobic-anaerobic transition in chronic liver diseases]

7 males, aged 30 to 60 years, with bioptically ascertained chronic liver diseases underwent a four-week preservance training programme on the bicycle ergometer in the aerobic-anaerobic transitional area (performance at 2-4 mmol 1(-1) lactate). The training caused a significant amelioration of the aerobic functional capacity of the test persons. The hypothesis of a liver-protective effect of the perserverance training was confirmed. The inclusion of a dosed physical training in the therapy and rehabilitation programme, respectively, of patients with chronic liver diseases can be recommended, particularly, since there is no causal medicamentous therapy of chronic liver diseases possible at present.

[Neuromyotonic syndrome]

A syndrome with constant rest activity was observed in the EMG of a 28-years-old female patient. An H-reflex was detected for normal nerve conduction velocity. Hypomagnesemia was striking among the laboratory values. Bioptic investigation yielded centralisation of nuclei, variations in the diameter of muscle fibres and a predominance of type I fibres. The findings and the response to Finlepsin point to neuromyotonic syndrome.

Detection of enteric adenoviruses by dot-blot hybridization using a molecularly cloned viral DNA probe

Enteric adenoviruses (EAds) (candidate adenoviruses 40 and 41, subgroups F and G) have been implicated in the etiology of gastroenteritis in infants, but their clinical significance has been unclear because a rapid test to distinguish these agents from other adenovirus (Ad) types has not been available. We developed a dot-blot hybridization assay for EAd DNA using a cloned DNA fragment that has little homology to non-EAd DNAs. The dot-blot system detected less than 20 pg of EAd DNA, while showing minimal cross hybridization to representative strains from all other Ad groups. There was no detectable hybridization to extracts of samples known to contain other enteric viruses. It was further shown that low levels of EAds in specimens could be amplified by culturing for 1 day in 293 cells. Stool samples and tissue culture lysates prescreened by electron microscopy, cell culture or ELISA were tested in a blind fashion. Using endonuclease analysis as the standard for typing the isolates, we found the dot-blot system to have a 91% sensitivity and 71% specificity for detecting EAds and distinguishing them from other Ads. False-positive and equivocal dot-blot results appeared to be caused by other Ads.

[Side effects of bilateral electroconvulsive therapy--comparative clinico-computer tomographic study]

The side effects of a five-times bilateral electric shock therapy were clinically and computer-tomographically investigated. A connection exists between the number of electric shock treatments which are carried out and the expression of a transitory organic psychosyndrome. However, no significant differences in relation to the initial findings were established a week after the completion of the treatment series despite great interindividual differentiation. Neither cerebral oedema or other signs of disturbances were computer-tomographically detectable as results of treatment. CT and clinic findings do not correspond to each other.

[Computer tomography and electromyography studies in patients with traumatic neuropathy]

Combined computerized tomography and neurophysiological techniques permit the simultaneous assessment of morphological and functional aspects associated with traumatic neuropathy. The simultaneous application of such techniques is one way of optimizing status analysis and prognosis .