Percutaneous fine needle aspiration biopsy of pancreatic cancer guided by ultrasonography

Fine needle aspiration biopsy guided by ultrasonography was performed in 39 patients with pancreatic cancer to evaluate the value of the technique for establishing a proved histologic diagnosis. Aspirated material suitable for cytologic evaluation of smear preparation was obtained from 33 patients (84.6%). Among the 33 patients, cytologic diagnosis of pancreatic cancer was possible in 28 patients (84.9%). There was mild abdominal pain only in one patient (2.6%). In conclusion, percutaneous fine needle aspiration biopsy guided by ultrasonography proved to be a safe and useful method for histologic diagnosis of pancreatic cancer.

Long-term results of antitachycardia pacing in patients with supraventricular tachycardia

Between 1979 and 1984 the Cybertach-60, (Intermedics, Inc. Model 262-01), a programmable, automatic antitachycardia pacemaker was implanted in 11 patients who had drug-refractory supraventricular tachycardia (SVT). The patients have been followed for a total of 64-108 (mean 84 months). All patients were symptomatic and had failed two or more drugs and six patients had required prior DC cardioversion. The mechanism of supraventricular tachycardia was atrioventricular (AV) nodal reentry in six patients, AV reentry in four patients, and atrial tachycardia in one patient. Preoperatively all patients had reliable termination of the tachycardia without induction of atrial fibrillation by pacing methods available to Cybertach-60. Postimplant, Cybertach-60 reliably terminated all episodes of tachycardia without ancillary drug therapy. Nevertheless, at long-term follow-up antitachycardia pacing was effective and safe in the minority (36%), with only four patients out of eleven still using a pacemaker for supraventricular tachycardia. One of these four patients required additional drug therapy. In one of the patients, the Cybertach-60 was replaced after 78 months by a more advanced device, (Intertach, Intermedics, Inc.) because of a depleted Cybertach-60 battery. In seven patients who no longer use antitachycardia pacing for termination of tachycardia, one patient developed atrial fibrillation during tachycardia termination (at 58 months postimplant). Three patients experienced induction of tachycardia or atrial fibrillation by the pacemaker due to undersensing of sinus P waves (at 36, 48, and 51 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Rat pancreatic nuclear thyroid hormone receptor: characterization and postnatal development

To document the presence of 3,5,3'-triiodothyronine nuclear receptor in the rat pancreas, the solubilized pancreatic nuclear fraction was characterized for its binding to 3,5,3'-L-triiodothyronine. Binding was found to be reversible, saturable, and specific. Scatchard analysis revealed a single class of 3,5,3'-L-triiodothyronine receptors in the pancreata of adult rats. The dissociation constant was 0.29 +/- 0.02 x 10(-9) M, and maximal binding capacity was 242 +/- 10 fmol of T3 bound per milligram of nonhistone protein at 30 degrees C (n = 20). Both parameters are comparable with those of adult rat liver nuclei. The degree of receptor occupancy was 30%-40% of the total sites in the adult rat pancreas. Developmentally, 3,5,3'-L-triiodothyronine binding was not detectable at birth and very low in pups less than 5 days old. It reached a peak at the third to fourth weeks. The degree of receptor occupancy changed with development from a low (19.2% +/- 2.0%) in 5-10-day-old pups to a high (50.5% +/- 3.0%) in 11-20-day-old pups, then returned to a moderate level (36.9% +/- 3.0%). The dissociation constants remained unchanged at various postnatal ages. Our data suggest that the rat pancreas is a target tissue for thyroid hormone and that thyroxine plays a role in pancreatic development.

Radioiodinated fatty acid esters in the management of hepatocellular carcinoma: preliminary findings

Radioiodinated fatty acid esters, such as lipiodol or ethiodol, are localized in the hypervascular hepatocellular carcinoma (HCC) for a long time following intra-arterial hepatic injection, enabling delivery of high internal radiation to the tumor. The desired radiation can easily be delivered to small HCC, less than 5 cm in diameter, in single or multiple procedures with an 8-week interval. For larger tumors, [131I]lipiodol or [131I]ethiodol in conjunction with chemotherapy emulsion, Ivalon embolization or all three combinations should be considered for maximal clinical results. A strong beta emitter with shorter physical half-life, i.e. 90Y will be more effective in the management of HCC if one can label lipiodol with 90Y.

Epidural anesthesia for acute pseudo-obstruction of the colon (Ogilvie's syndrome)

With the theory that Ogilvie's syndrome is caused by sympathetic inhibition of contractility in the colon as a basis, 18 patients with acute colonic pseudo-obstruction were enrolled in a treatment program assessing the safety and efficacy of sympathetic blockade, by epidural anesthesia, in those who failed conservative management. In some cases colonoscopy had been performed initially and, if unsuccessful, these patients were referred for treatment with epidural anesthesia. Seven patients recovered with conservative treatment alone. One patient refused further treatment and died of her underlying disease. Five of eight patients treated by epidural anesthesia responded. There were no recurrences following successful epidural anesthesia. Five of eight patients treated by colonoscopic decompression responded. No patients required surgical intervention. One patient suffered a subendocardial infarction during colonoscopy. There were no significant complications from epidural anesthesia. Epidural anesthesia is safe, effective, simple, and well tolerated in the management of Ogilvie's syndrome.

Fibrous hamartoma of infancy

Fibrous hamartoma of infancy is an uncommon, benign, subcutaneous fibrous proliferation, usually found during the first 2 years of life. It predominantly affects healthy boys and can be found in almost any subcutaneous tissue. This tumor can cause much concern about malignancy because it is firm and may be fixed to underlying tissues. Despite the occasional local recurrence, the clinical course is benign and the prognosis is excellent. Treatment is by local excision. The diagnosis is made easily by the characteristic histologic features. In order to avoid the misdiagnosis of malignancy and unnecessary radical therapy, both surgeon and pathologist must be familiar with this entity. We have reviewed six cases of fibrous hamartoma of infancy seen over a 5-year period.

Electrophysiologic effects of intravenous and oral sotalol for sustained ventricular tachycardia secondary to coronary artery disease

The electrophysiologic effects of intravenous sotalol (1.5 mg/kg load followed by 0.008 mg/kg maintenance, mean dose 150 +/- 23 mg) and oral sotalol (mean dose 583 +/- 204 mg daily) were prospectively evaluated in 16 patients undergoing electrophysiologic evaluation for sustained ventricular tachycardia (VT) secondary to coronary artery disease. Electrocardiographic intervals, indexes of sinus and atrioventricular node function and indexes of atrial and ventricular function were assessed. Inducibility or noninducibility of sustained VT and characteristics of the induced arrhythmia were also evaluated. Intravenous and oral sotalol exerted similar beta-blocking effects, which included significant prolongation of sinus cycle length (baseline 820 +/- 165 ms, intravenous sotalol 1,077 +/- 206 ms, oral sotalol 1,141 +/- 306 ms), AH interval (baseline 126 +/- 43, intravenous sotalol 169 +/- 42, oral sotalol 197 +/- 55 ms) and Wenckebach cycle length (baseline 375 +/- 70, intravenous sotalol 460 +/- 84, oral sotalol 449 +/- 68 ms). Both intravenous and oral sotalol also prolonged repolarization and refractoriness including significant increases in QT interval (baseline 338 +/- 47, intravenous sotalol 417 +/- 35, oral sotalol 450 +/- 70 ms), atrial effective refractory period (baseline 240 +/- 38, intravenous sotalol 330 +/- 71, oral sotalol 299 +/- 26 ms) and right ventricular effective refractory period (baseline 241 +/- 16, intravenous sotalol 289 +/- 35, oral sotalol 291 +/- 22 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of hepatocellular carcinoma (HCC) with radiolabeled Lipiodol: a preliminary report

Fatty acid esters such as Lipiodol or Ethiodol (Savage Laboratories, Melville, New York) are known to selectively localize in vascular hepatocellular carcinomas (HCC), following intra-arterial hepatic administration. Lipiodol was labeled with radioactive 131I and administered in 47 patients with HCC for both imaging and therapy. The short term preliminary results suggest radiolabeled Lipiodol is effective in eliminating ascites, shrinking the tumor by a high internal radiation dose, and in improving symptomatology of these tumors. In the future, 90Y, which is a stronger pure beta-emitter (maximum beta energy of 2.27 MeV, a half life of 64 h, and a maximum penetration or beta range of 11mm), than 131I will be used for more effective treatment of HCC.

Determinants of induced sustained arrhythmias in survivors of out-of-hospital ventricular fibrillation

We prospectively studied 196 consecutive survivors of out-of-hospital ventricular fibrillation (VF) not associated with acute myocardial infarction and 46 consecutive, control patients without prior ventricular arrhythmias. Programmed stimulation included two extrastimuli (S3 protocol) in all patients and three extrastimuli (S4 protocol) in the last 140 study patients and in all control patients. Sustained ventricular tachycardia (VT) or VF was not induced in any control patient. In study patients, logistic regression identified two independent predictors of induced, sustained VT for both S3 and S4 protocols: prior spontaneous, sustained VT (37 patients; p less than or equal to .001) and prior myocardial infarction (113 patients; p = .005). With the S3 protocol, sustained VT was induced in 54% of patients with both prior myocardial infarction and prior sustained VT vs 4% without either; with the S4 protocol, sustained VT was induced in 91% vs 13%, respectively. Eighty-three percent of induced VT episodes had a cycle length less than 300 msec, and all required termination by cardioversion or pacing. VF was induced only in survivors of out-of-hospital VF without prior, spontaneous, sustained VT (S3 protocol, 9%; S4 protocol, 24%) but not in study patients with prior sustained VT (S3, p = .10; S4, p = .05) or control patients (S3, p = .06; S4, p = .01). The mean coupling intervals of extrastimuli that induced VF were not significantly different from the intervals that induced sustained VT.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of acute intravenous and chronic oral amiodarone on defibrillation energy requirements

Amiodarone is commonly used with the automatic implantable defibrillator to treat recurrent ventricular tachyarrhythmias. The effects of acute intravenous and chronic oral amiodarone on the energy requirements for successful defibrillation were evaluated in 12 dogs chronically instrumented with right atrial spring and left ventricular patch defibrillation electrodes. Multiple shocks of varying energy were applied in balanced random order to construct curves of percent successful defibrillation vs energy (DF curves) on each test day. Dogs were studied on days 1, 11, 18, 25, and 32. On day 11, DF curves were determined before and after infusing saline (n = 6) or amiodarone (n = 6), 10 mg/kg loading and 0.33 mg/kg/min maintenance doses. Dogs administered intravenous amiodarone were continued on oral drug (300 mg twice daily) for the remainder of the study. Data were analyzed by logistic regression and the energy required for 50% (E50) and 80% (E80) successful defibrillation were compared. Differences between controls and animals receiving chronic oral amiodarone were not significant on any day. After acute intravenous infusion, dogs given amiodarone had a 21.7 +/- 12.8% decrease in E50 (p less than 0.01) and a 19.7 +/- 17.8% decrease in E80 (p less than 0.05), while controls had an 11.4 +/- 30.5% increase (p = NS) in E50 and 6.30 +/- 30.5 increase in E80 (p = NS). It is concluded that the energy required for successful defibrillation is decreased by acute intravenous amiodarone, while chronic oral administration has no significant effect.

Influence of hepatic dysfunction on the pharmacokinetics of propafenone

Hepatic metabolism is the primary process of elimination of propafenone. It therefore is important to understand the effect of altered liver function on the disposition and elimination kinetics of this drug. Patients with abnormal liver function probably will require treatment with propafenone for cardiac arrhythmias; an understanding of the relationship between liver function and the pharmacokinetics of propafenone will provide a rational basis for optimal dosage adjustments in these individuals. Our results demonstrate that both systemic clearance and bioavailability of propafenone are sensitive to variability in liver function. The bioavailability of propafenone is inversely related to the clearance of indocyanine green (ICG), whereas a direct relationship exists between systemic clearance of propafenone and ICG clearance. Comparisons of clinical parameters with the propafenone data yielded interesting results. An overall clinical grading of severity of liver disease based on the presence or absence of portal hypertension (i.e., varices and/or splenomegaly), prior encephalopathy, and ascites did not correlate well with propafenone results. However, albumin, total bilirubin, serum glutamic oxaloacetic transaminase (SGOT) concentrations and prothrombin time values correlated strongly with the overall results. No definite relationships with subjects' age; weight; and hemoglobin, alkaline phosphatase, lactic acid dehydrogenose, cholesterol, blood urea nitrogen, or creatinine levels were detected. These results demonstrate that moderate to severe liver disease significantly affects the absorption and disposition of propafenone. In patients with cirrhosis, and presumably other forms of hepatic dysfunction, careful adjustments of propafenone doses are needed to optimize therapy.

Postprandial alterations in hemodynamics and blood pressure in normal subjects

The effects of a standardized mixed meal, a self-selected meal and a sham meal on heart rate, arterial pressure, cardiac output, total systemic resistance and echocardiographic indexes of left ventricular performance were examined in normal volunteers. Supine heart rate and cardiac output increased after the meals (p less than 0.07 to 0.001), but not after the sham meal. Supine diastolic blood pressure and total systemic resistance decreased after the meals but not after the sham meal (p less than 0.05 to 0.001). Ejection fraction and mean velocity of circumferential fiber shortening increased after the standard meal (p less than 0.01) and tended to increase after the self-selected meal, but did not increase after the sham meal. Meals of normal size may induce splanchnic vasodilation and a decrease in total systemic resistance. Ingestion of food also significantly affects heart rate, blood pressure, cardiac output and echocardiographic indexes of left ventricular performance. Patients should not eat during short-term evaluation of cardiovascular interventions because the cardiovascular effects of a meal may compromise interpretation of the cardiovascular effects of the primary intervention. The hemodynamic effects of food may also interact with the effects of cardiovascular disease processes.

Ethmozine: electrophysiology, hemodynamics, and antiarrhythmic efficacy in patients with life-threatening ventricular arrhythmias

Thirteen patients with drug-resistant, life-threatening ventricular arrhythmias and inducible sustained ventricular tachycardia (VT) at electrophysiologic study received moricizine HC1 (ethmozine), 10 mg/kg/day orally. Eight patients underwent electrophysiologic study before and after drug administration; the arrhythmia became noninducible in one. In five other patients, spontaneous sustained VT occurred after 1 to 5 days of drug therapy, and one patient had a worsening of arrhythmias on ethmozine. Ethmozine prolonged infranodal conduction time (HV interval) (51.4 +/- 13.8 msec to 69.3 +/- 17.7 msec [mean +/- SD]), PR interval (201 +/- 28.1 msec to 244 +/- 62.2 msec), and QRS interval (123 +/- 27 msec to 147 +/- 32 msec). Ventricular refractory periods were not consistently affected, and only the one patient who became noninducible had an increase in effective ventricular refractory period (280 to 310 msec). The drug had no significant effect on sinus cycle length or sinus node recovery time, atrial conduction or refractoriness, or atrioventricular nodal refractoriness. Ethmozine had no effect on radionuclide ejection fraction (25.5 +/- 12.7% to 28.2 +/- 13.8%) or cardiac index (2.4 +/- 0.7 to 3.0 +/- 0.6 ml/min/m2) and caused no significant changes in mean aortic, right atrial, pulmonary arterial, or pulmonary capillary wedge pressures. Although the drug is well tolerated and produces no untoward hemodynamic effects, ethmozine is relatively ineffective in patients with sustained VT refractory to conventional antiarrhythmic agents.

Evaluation of intrahepatic I-131 ethiodol on a patient with hepatocellular carcinoma. Therapeutic feasibility study

This study assesses the therapeutic efficacy of radiolabeled iodized oil on a patient with hepatocellular carcinoma (HCC). An iodized oil, such as Lipiodol or Ethiodol (Savage Laboratories, Melville, NY), was retained selectively in the tumor vessels of large tumors as well as in the daughter tumors of HCC for long periods of time following intra-arterial injection into the hepatic artery proper. A small fraction of the stable iodine (1 pg of I-127) of the 37% iodine by weight in Ethiodol was replaced by the I-131 with 100% efficiency. A patient with HCC was injected with I-131 Ethiodol into the hepatic artery. Sequential imaging of organs such as the liver, lung, stomach, and thyroid over an eight-day period demonstrated a high tumor-to-normal-liver ratio and a negligible amount of radioactivity in these organs. These findings indicate that I-131 Ethiodol, or Ethiodol labeled with other pure beta emitters, such as Y-90 or P-32, will be effective delivering a high internal radiation dose to HCC with a small radiation effect to normal tissues. To evaluate its potential as a radiotherapeutic agent for HCC, the kinetics, biodistribution, determination of absolute activity in the tumor following intra-arterial injection of I-131 Ethiodol will be studied in the future. At the same time, an effort will be made to label Ethiodol with Y-90 and P-32.

Benign extrinsic compression of the common bile duct: a case report

Painless obstructive jaundice is usually the result of malignant compression of the distal common bile duct. Infrequently extrinsic benign lesions may also cause ductal obstruction and be mistaken for a malignant process. A case of compression of the distal common bile duct is described. Preoperative evaluation was most consistent with a cystadenocarcinoma of the head of the pancreas. At operation we found an enlarged and calcified periductal lymph node with associated fibrosis and compression and obstruction of the distal common duct. Massive dilatation of the distal common duct and the cystic duct remnant gave it the appearance of a cystic mass in the superior border of the head of the pancreas. Resection and choledochoduodenostomy were curative.

Adenosine receptors in an enriched fraction of plasma membranes from canine ventricular myocardium

[3H]Phenylisopropyladenosine ([3H]PIA) was used to characterize adenosine receptor sites in a sarcolemma-enriched membrane fraction from canine ventricle. Specific [3H]PIA binding to the cardiac membrane preparation was rapid, readily reversible, and saturable with increasing free ligand concentrations. Scatchard analysis indicated a single class of binding sites having a Bmax of 601 fmol/mg protein. The Kd of [3H]PIA for its binding site was 52-85 nM as determined independently from kinetic and equilibrium studies, respectively. Binding was stereospecific in that (-)PIA was ninefold more potent than (+)PIA in competing for [3H]PIA binding sites. Adenosine receptor agonists such as N6-cyclohexyladenosine, (-)PIA, 2-chloroadenosine, N6-methyladenosine, and adenosine-5'-ethylcarboxamide were the most potent agents found to compete for [3H]PIA binding sites and displayed IC50 values of 14-224 nM, while 2',5'-dideoxyadenosine, a potent P-site agonist, inhibited binding only weakly. Alkylxanthines also inhibited [3H]PIA binding with relative potency relationships that paralleled their known pharmacological activity as adenosine receptor antagonists. (-)PIA inhibited activation of membrane adenylate cyclase by isoproterenol in a concentration-dependent manner with a maximum of 22% inhibition occurring at 1 microM PIA. It is concluded that the specific binding of [3H]PIA to the sarcolemma-enriched fraction of canine ventricle represents an Ri adenosine receptor on the surface of the myocardial cell. Such a receptor has been postulated to mediate the adenosine-induced attenuation of the effects of catecholamines on intact ventricular myocardium.

Serum fatty acid concentrations in patients on postoperative parenteral nutrition with and without fat

To examine changes in fatty acid composition of serum lipids, sixteen patients with gastric cancer were maintained on total parenteral nutrition (TPN) or intravenous feeding immediately after total gastrectomy. Subjects receiving no fat showed decreases in linoleic acid, linolenic acid and arachidonic acid and increases in palmitoleic acid and oleic acid, whereas those receiving fat emulsion showed no detectable changes. Decrease in the linoleic acid content was greater in subjects on a higher carbohydrate intake, but less in those on a higher fat intake. Multiple regression analysis of the relationships among carbohydrate intake (X1) and fat intake (X2) and changes in the linoleic acid percentage of total serum fatty acids (Y) in each case yielded an equation: Y =-4.75 X1 + 69.0 X2 - 27.9 (R = 0.885, p less than 0.05). Approximately 1 g/kg/day of fat provided in 40-50 kcal/kg/day of nonprotein energy intake was estimated to prevent decrease in the linoleic acid content in the serum fatty acid pattern during the postoperative catabolic stage.

Fluorescence polarization immunoassay for theophylline modified for use with dried blood spots on filter paper

We used dried blood spots successfully as alternative specimens for quantifying concentrations of theophylline in the circulation by a modified fluorescence polarization immunoassay (FPIA) with the Abbott TDx instrument. The method described is simple, rapid, and acceptably precise. More importantly, it can provide results comparable with those of the conventional serum assay. Results for 64 pairs of dried blood spots (y) and serum (x) specimens analyzed by the respective FPIA methods yielded the following regression parameters: y = 0.94x + 0.71, r = 0.988, and Sxy = 0.92. A major advantage of FPIA is that it requires only basic laboratory skills. When coupled with the use of dried blood spots, this system can be effective in remote theophylline monitoring, particularly suited for domiciliary care.

Fluorescence polarization immunoassay for theophylline modified for use with dried blood spots on filter paper

We used dried blood spots successfully as alternative specimens for quantifying concentrations of theophylline in the circulation by a modified fluorescence polarization immunoassay (FPIA) with the Abbott TDx instrument. The method described is simple, rapid, and acceptably precise. More importantly, it can provide results comparable with those of the conventional serum assay. Results for 64 pairs of dried blood spots (y) and serum (x) specimens analyzed by the respective FPIA methods yielded the following regression parameters: y = 0.94x + 0.71, r = 0.988, and Sxy = 0.92. A major advantage of FPIA is that it requires only basic laboratory skills. When coupled with the use of dried blood spots, this system can be effective in remote theophylline monitoring, particularly suited for domiciliary care.

Acute hypotensive effects of oral and intravenous propranolol: early alterations in peripheral resistance

The effects of single oral and intravenous doses of propranolol on blood pressure and hemodynamics were measured in normal volunteers. Systolic and diastolic blood pressure decreased 10% within 3 hours after the oral dose and by 3%-5% after the intravenous dose. Cardiac output decreased 16% after the intravenous dose and 10% after the oral dose. Total peripheral resistance transiently increased by 23% after the intravenous, but not after the oral dose. Change in mean arterial pressure was positively correlated with change in total peripheral resistance after both the oral and intravenous doses. In contrast, change in mean arterial pressure was negatively correlated with change in cardiac output after the intravenous dose. Single oral and intravenous doses of propranolol lowered blood pressure within 3 hours after administration, and the reduction was correlated with change in total peripheral resistance and not with change in cardiac output. At least part of the adaptation in peripheral resistance occurs within the first 3 hours after both oral and intravenous single doses of propranolol.

Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study

In a one-year period, 149 adult cases of Clostridium difficile-associated diarrhea and colitis were compared with 148 diarrhea-free controls. Eighty-seven percent were nosocomial and 75% were on surgical services. Endoscopy revealed pseudomembranes in 51% of the 109 cases in which stool cytotoxin was present, compared with 11% of the 40 cases that were culture-positive but cytotoxin-negative. Cases diagnosed only by stool culture showed essentially no differences from controls, 21% of whom had asymptomatic stool colonization. We estimate that only 20% of these cases had diarrhea due to C difficile. Compared with controls, cases diagnosed by the presence of cytotoxin or pseudomembranes were found to have been hospitalized longer at diarrhea onset, to have had more antecedent infections, and to have received clindamycin, multiple antimicrobials, and therapeutic antimicrobials more often than controls, but controls received prophylactic antimicrobials more frequently than cases. Cultures of the environment, patients, and personnel failed to detect a mechanism of acquisition.

Three-year experience with amikacin sulfate as an exclusive surgical aminoglycoside in a large acute-care hospital

Aminoglycosides have important roles as perioperative adjunctive antibiotics in the surgical management of peritonitis. In the past, most surgeons have used gentamicin in combination with a drug aimed at intraperitoneal anaerobic pathogens, either clindamycin or metronidazole. Amikacin has been traditionally reserved for culture-proved infections due to gram-negative organisms resistant to gentamicin or other aminoglycosides. At the Minneapolis Veterans Administration Medical Center, a worrisome incidence of gentamicin-resistant hospital isolates led to a decision to make amikacin the exclusive, routine surgical aminoglycoside for all abdominal infections, as well as all hospital-acquired infections in surgical patients involving gram-negative aerobes and requiring parenteral therapy. This report describes the resultant three-year experience with amikacin in surgical patients. Data from four research studies involving these patients suggest that exclusive amikacin use has not led to the emergence of amikacin-resistant organisms or to significant nephrotoxicity. Amikacin use in surgical patients is supported in hospital environments where gentamicin resistance is judged to be a significant clinical risk factor.

Airway obstruction due to massive lingual oedema following cleft palate surgery

The Pierre Robin syndrome consists of micrognathia, pseudo-macroglossia, glossoptosis and a high arched or cleft palate. Difficult intubation of the trachea and associated abnormalities such as congenital heart disease are well known complications of this syndrome. Intraoral surgery (such as cleft palate repair and palatoplasty) can also be technically difficult for the surgeon resulting in prolonged retraction on the tongue with a mouth gag to provide adequate surgical exposure. We report a case where massive lingual oedema following a cleft palate repair resulted in life-threatening airway obstruction.

Co-translational excision of alpha-glucose and alpha-mannose in nascent vesicular stomatitis virus G protein

Membrane bound polysomes were prepared from HeLa cells infected with vesicular stomatitis virus (VSV), after pulse labeling with [3H]mannose for various times from 15 to 90 min. Oligosaccharides on nascent chains were released from peptides by treatment with endoglycosidase H and sized by high resolution Biogel P4 chromatography. Processing on some nascent chains proceeded to the removal of all three types of alpha-linked glucose and one alpha-1,2-mannose from the Glc3Man9GlcNAc precursor showing that the enzymes responsible were not only active on nascent chains but were present in the rough endoplasmic reticulum (RER). Incubation of cells for various times in cycloheximide, where chain elongation had ceased, made no difference to the profile of oligosaccharides on the nascent chains, and trimming proceeded no further than Man8GlcNAc2Asn . Carbonyl cyanide m-chlorophenylhydrazone (CCCP), an energy inhibitor reportedly able to block the transfer of glycoproteins from the RER, increases the amount of Man8-oligosaccharides on the nascent chains and also the amount of Glc3Man9GlcNAc precursor. On completed G protein in the RER fraction from which membrane bound polysomes were prepared, processing occurred to Man6 - but not to Man5GlcNAc sized oligosaccharides in the CCCP-treated cells. By contrast, processing to Man5GlcNAc oligosaccharides was observed in unfractionated control cells.

Primary malignant fibrous histiocytoma of the lung. A clinicopathologic and ultrastructural study of five cases

Primary sarcomas of the lung are rare malignant neoplasms which have usually been classified as fibrosarcomas or as leiomyosarcomas. Only five cases of primary malignant fibrous histiocytoma (MFH) of the lung have previously been reported in the literature. The authors reviewed 10 cases of primary pulmonary sarcoma of the lung seen at their institution during the last 12 years, and five of these cases met the morphologic criteria for the diagnosis of MFH. The morphology in these cases is identical to MFH of other body locations, and shows a combination of fibroblast-like and histiocyte-like cells at both the light and electron microscopic level. By electron microscopic examination there was no evidence for anaplastic carcinoma, rhabdomyosarcoma, or leiomyosarcoma. Of the three patients with adequate follow-up, one patient is alive without evidence of disease at 10 years, one died at 5 years without evidence of recurrent sarcoma, and one died at 7 months with liver metastasis. Two other patients are alive without recurrence at 8 months and 1 year, respectively, following surgery. Because MFH is primarily a tumor of the soft tissues of the extremities, patients with MFH of the lung must be carefully evaluated to rule out a metastatic origin. The reported prognosis in patients with primary MFH of the lung is poor, but early surgical resection does offer the possibility of a cure.

Rapid quantification of pentobarbital in serum by fluorescence polarization immunoassay

The commercially available fluorescence polarization immunoasay (FPIA) method for phenobarbital is demonstrated to be useful in the quantification of pentobarbital in serum. The effective range for the method is 1.0 to 80.0 mg/L. The method is simple, precise, and fast. The application of the method is limited to patients receiving pentobarbital as the only barbiturate. The FPIA is recommended for use in clinical laboratories when a rapid estimation of pentobarbital is required in monitoring patients undergoing high-dose pentobarbital therapy.

Rapid quantification of pentobarbital in serum by fluorescence polarization immunoassay

The commercially available fluorescence polarization immunoasay (FPIA) method for phenobarbital is demonstrated to be useful in the quantification of pentobarbital in serum. The effective range for the method is 1.0 to 80.0 mg/L. The method is simple, precise, and fast. The application of the method is limited to patients receiving pentobarbital as the only barbiturate. The FPIA is recommended for use in clinical laboratories when a rapid estimation of pentobarbital is required in monitoring patients undergoing high-dose pentobarbital therapy.

Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis

101 patients with Clostridium-difficile-associated diarrhoea or colitis were prospectively randomised to 10-day oral courses of metronidazole, 250 mg four times a day, or vancomycin, 500 mg four times a day. 7 did not complete the protocol and were dropped from analysis. Pseudomembranous colitis (PMC) was diagnosed after endoscopy in 33 patients. Of the remaining patients without PMC, 38 had both C difficile culture and cytotoxin and 23 had only culture evidence of C difficile. 52 evaluable patients received vancomycin and 42 received metronidazole. There were two treatment failures with metronidazole and none with vancomycin (p = 0.20); and two relapses with metronidazole versus six with vancomycin (p = 0.17). Treatment in 1 patient in each group was discontinued because of drug intolerance. Response and relapse rates of the 33 patients with PMC were no different from those of the remaining patients. Pharmacy cost for the dosage used was $387.48 to $520.00 for vancomycin and $11.84 for metronidazole. Metronidazole and vancomycin have equivalent efficacy and relapse rates and are tolerated to a similar extent by patients with C-difficile-related diarrhoea and colitis, but metronidazole is considerably more economical.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. VII. Hemoglobin does not inhibit clearance of Escherichia coli from the peritoneal cavity

Hemoglobin has been shown to be a potent adjuvant in experimental Escherichia coli peritonitis, although a satisfactory mechanistic rationale is still obscure. Hemoglobin has been thought to impair intraperitoneal neutrophil function, delay clearance of bacteria from the peritoneal cavity by the normal absorptive mechanisms, or directly enhance bacterial growth. Using highly purified stroma-free hemoglobin (SFHgb), we have largely discounted any direct effect of hemoglobin on peritoneal white blood cell function. In the present study, we confirmed that uncontrolled proliferation of bacteria takes place in the presence of hemoglobin in the peritoneal cavity. Nonviable 5-iododeoxyuridine 125I-labelled bacteria were then used to directly study peritoneal clearance kinetics, eliminating the problem of bacterial growth. SFHgb had no influence on the removal of intraperitoneal bacteria. The rate of bloodstream appearance of radiolabel was similar with or without intraperitoneal SFHgb. Thus, SFHgb does not prevent clearance of bacteria from the peritoneal cavity by interfering with normal host clearance mechanisms. SFHgb may act as a bacterial growth adjuvant, either by serving as a bacterial nutrient or by suitably modifying the environment so that extensive bacterial proliferation can occur. The latter hypothesis appears to be an area in which investigation concerning the adjuvant effect of hemoglobin may prove most fruitful.

Elevated plasma beta-hydroxybutyrate concentrations without ketonuria in healthy insulin-dependent diabetic patients

Plasma beta-hydroxybutyrate (beta-OHB) concentrations and simultaneous urine tests for ketonuria (nitroprusside reaction) were evaluated every 4 h throughout a 24-h study in 10 healthy insulin-dependent diabetics who had poor control based on home urine tests and elevated hemoglobin A1C. Concurrent measurements of the major carbohydrate regulatory hormones were made in the diabetic group and in a control population of 20 age-matched subjects. In the diabetics, 73% of the beta-OHB measurements were elevated. Only 43% of the abnormal beta-OHB values were associated with ketonuria. The diabetic subjects also showed exaggerated diurnal patterns for plasma beta-OHB and cortisol. There were no significant differences for the other regulatory hormones in the diabetic and normal groups. We conclude that 1) abnormal plasma beta-OHB levels without ketonuria are prevalent in poorly controlled diabetics; 2) negative nitroprusside tests for ketonuria underestimate the presence of ketonemia due to increased beta-OHB concentrations; 3) both insulin deficiency and glucocorticoid excess may influence ketone body metabolism in insulin-dependent diabetic patients.

Haptoglobin: a natural bacteriostat

The combination of bacteria and blood in a wound can have lethal consequences, probably because hemoglobin iron supports prolific bacterial growth. Rats inoculated intraperitoneally with pathogenic Escherichia coli and small amounts of hemoglobin die. Simultaneous administration of haptoglobin, a naturally occurring hemoglobin-binding protein, fully protects against lethality. Therefore, haptoglobin may not only accelerate the clearance of free hemoglobin, but also limit its utilization by adventitious bacteria. Haptoglobin may have therapeutic potential in the treatment of life-threatening, hemoglobin-driven bacterial infections.

Improved method for determining erythrocyte creatine by the diacetyl-alpha-naphthol reaction: elimination of endogenous glutathione interference

We describe a simple, accurate, and reproducible method for determining erythrocyte creatine. The method is free from glutathione inhibition and is adaptable to use with standard spectrophotometers as well as centrifugal analyzers. A clear filtrate, essentially free of protein, hemoglobin, and glutathione, is prepared from 0.1 mL of packed erythrocytes by treatment with Ba(OH)2 and ZnSO4, then reacted with diacetyl-alpha-naphthol. The standard curve for this method is linear from 10 to 500 mg/L. We show that endogenous sulfhydryl species such as erythrocyte glutathione will interfere with the creatine-diacetyl-alpha-naphthol reaction. This observation confirmed a suspicion of underestimation of erythrocyte creatine by the method of Griffiths (Clin. Chim. Acta 9: 210, 1964). Added p-chloromercuribenzoic acid did not completely eliminate this inhibition. In the present method these interfering sulfhydryl species are eliminated from the reaction mixture, thus obviating the need for p-chloromercuribenzoic acid and dialysis. The reference interval for this method is 42-80 mg/L.

Improved method for determining erythrocyte creatine by the diacetyl-alpha-naphthol reaction: elimination of endogenous glutathione interference

We describe a simple, accurate, and reproducible method for determining erythrocyte creatine. The method is free from glutathione inhibition and is adaptable to use with standard spectrophotometers as well as centrifugal analyzers. A clear filtrate, essentially free of protein, hemoglobin, and glutathione, is prepared from 0.1 mL of packed erythrocytes by treatment with Ba(OH)2 and ZnSO4, then reacted with diacetyl-alpha-naphthol. The standard curve for this method is linear from 10 to 500 mg/L. We show that endogenous sulfhydryl species such as erythrocyte glutathione will interfere with the creatine-diacetyl-alpha-naphthol reaction. This observation confirmed a suspicion of underestimation of erythrocyte creatine by the method of Griffiths (Clin. Chim. Acta 9: 210, 1964). Added p-chloromercuribenzoic acid did not completely eliminate this inhibition. In the present method these interfering sulfhydryl species are eliminated from the reaction mixture, thus obviating the need for p-chloromercuribenzoic acid and dialysis. The reference interval for this method is 42-80 mg/L.

Myocardial infarct size and location in relation to the coronary vascular bed at risk in man

Recent infarcts were compared with the anatomic boundaries of the involved vascular bed in human hearts to determine the amount and location of necrosis in relation to the myocardium at risk. The coronary arteries were injected with BaSO4 in 18 human hearts with 3-16-day-old infarcts. Thin (3-4 mm) slices were cut at 10-15 mm intervals, photographed, x-rayed and used for histologic analysis. Infarct outlines were traced from gross photographs using histologic confirmation of infarct boundaries, and the vascular bed was independently traced from the x-rays. Ischemic bed size and infarct size were then calculated by computerized planimetry. Infarct size ranged from 13-72% of the left ventricle (mean 30 +/- 3.6%) and was linearly related to the size of the occluded vascular bed (r = 0.93). However, the infarcts were always smaller than the occluded beds. They involved 50-88% of the ischemic bed (mean 69 +/- 3.0%) due to variation in the transmural extent of necrosis. A lateral zone of viable muscle within the ischemic bed was present but was consistently narrow (mean 1.7 +/- 0.3 mm) so that the infarcts involved 93 +/- 2.3% of the width of the bed at risk. Thus, ischemic bed size is a major determinant of infarct size in fatal human infarcts. When natural limitation of infarct size occurs, it is due primarily to limitation of the transmural extent of necrosis.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. IV. The adjuvant effect of hemoglobin in granulocytopenic rats

Intraperitoneal inocula of pure Escherichia coli do not produce lethal peritonitis unless adjuvant materials are present. We have previously presented evidence that hemoglobin acts as an adjuvant in experimental Escherichia coli peritonitis by interfering with antibacterial neutrophil function. The hypothesis was further tested in normal Sprague-Dawley rats and rats depleted of granulocytes by pretreatment with busulfan and cyclophosphamide. Hemoglobin increased the lethality of Escherichia coli peritonitis in both neutropenic and normal rats. Furthermore, the early clearance of bacteria from the peritoneal cavity was equally depressed by hemoglobin in neutropenic and normal rats. We conclude that hemoglobin has some effect on intraperitoneal infections beyond its suppression of granulocyte function. This additional effect may represent interference with bacterial lymphatic absorption or peritoneal or systemic macrophage function or may be a manifestation of a nutritional effect of hemoglobin on bacterial growth.