Hemodynamic and gas exchange alterations during Intralipid infusion in patients with adult respiratory distress syndrome

Hemodynamic and pulmonary gas exchange consequences of 20 percent intravenous fat emulsion infusion (3.0 +/- .3 mg/kg/min) were evaluated in 19 patients who demonstrated ARDS. Lipid infusion precipitated a significant reduction in PaO2/FIO2 from 241 +/- 50 to 184 +/- 41 (mean +/- SD) and increased MPAP from 26.0 +/- 5.1 to 31.8 +/- 4.8 mm Hg, pulmonary vascular resistance from 149 +/- 78 to 179 +/- 61 dyne.s/cm5 and pulmonary venous admixture (Qva/Qt) from 20.7 +/- 15.2 to 30.6 +/- 8.6 percent. Further analysis revealed that the magnitude of increased Qva/Qt was greater in patients who manifested septicemia (N = 10) compared to those who did not (N = 9): 12.3 vs 7.3 percent, respectively. We conclude that intravenous lipid administration was associated with increased MPAP and Qva/Qt in patients with ARDS, particularly when accompanied by septicemia. Although these alterations resolved after the lipid infusion was terminated, we suggest that prudent measures should be taken to guarantee adequate oxygenation during intravenous fat emulsion therapy in patients suffering from ARDS.

Can general practitioners use training in relaxation and management of stress to reduce mild hypertension?

To see whether general practitioners could effectively carry out training in relaxation and management of stress to reduce mild hypertension a study was carried out with a subsample of phase 2 of the Medical Research Council's treatment of mild hypertension trial. In the main mild hypertension trial patients had been receiving either an active drug or placebo for six years. In phase 2 a subsample of these patients were randomly allocated either to continue or to stop receiving the active drug or placebo. In a further subsample patients were again randomised to receive or not to receive relaxation therapy. This factorial design presented an additional opportunity to assess whether patients controlled with active drugs might have their blood pressure maintained by this behavioural therapy once drug treatment was stopped and to assess whether blood pressure might be further reduced by this therapy in patients who had been under regular medical supervision for as long as six years and who had already received non-pharmacological advice. The therapy was conducted by general practitioners in group sessions once a week for eight weeks. The training in relaxation was accompanied by galvanic skin resistance biofeedback. At one year follow up blood pressure in the relaxation subgroups was either maintained (in the group who had stopped receiving drugs) or reduced further (in the group who had continued receiving drugs and in both placebo groups), while in the control group it had increased in all the subgroups, but particularly in those who had stopped receiving drugs. Differences in changes in blood pressure between the relaxation and control groups were significant. There were five new cardiovascular events, including evidence of myocardial ischaemia in blindly coded electrocardiograms in the control group, compared with one in the treatment group. General practitioners, if motivated, can successfully apply this technique of training those with mild hypertension in relaxation and management of stress.

Aneurysms of the pulmonary arteries--a case report

A fifty-five-year-old male demonstrated over a three-year period marked enlargement of pulmonary aneurysms. This can be a fatal condition owing to rupture of the aneurysms.

Stress management, blood pressure and quality of life

This paper addresses three questions. First, we examine the effectiveness of relaxation and stress management in reducing hypertension and its complications by reviewing published studies including our own. Secondly, we report quality of life under such treatment, and thirdly, we discuss possible mechanisms. There is considerable evidence to show the effectiveness of a variety of non-pharmacological measures. In a randomized, controlled trial we showed that relaxation and stress-management training was associated with a reduction in blood pressure (BP) maintained over 4 years of observation. There were signs of a possible reduction in coronary heart disease (CHD) risk while maintaining or even enhancing the quality of life. Significantly more subjects in the relaxation group reported improved relationships at work, general health, enjoyment of life, and personal and family relationships than those in the control group at a 4-year follow-up. A similar but statistically insignificant trend was shown for the general level of physical energy, sexual life, concentration at work, mental well-being and social life. The relaxation group also displayed a belief in greater control over their health. There was no consistent relationship between the degree of reduction in BP and improvement in the above aspects of life, but those who practised relaxation regularly, who integrated relaxation in everyday activities and who used cognitive reappraisal as part of their stress-management strategies, showed greater reduction in BP than those who did not. Other studies have shown that this therapy can contribute significantly to the better control of BP with smaller doses of antihypertensive drugs, thus reducing the chances of side effects.

Long-term threshold stability with porous tip electrodes

Experience with 163 unipolar tined porous endocardial electrodes is reported. One patient required repositioning of the electrode because of exit block. There were no other complications in the entire series of patients. All of the patients had low chronic stimulation thresholds. The mean pulse width 24 hours after implantation was 0.0534 +/- 0.0128 ms. Seventy-four patients were restudied six months after implantation. The mean pulse width threshold was then 0.07432 +/- 0.0775 ms. Fifty-four patients were evaluated one year after lead implantation. The mean pulse width threshold was then 0.0611 +/- 0.0230 ms. The pulse generator was reprogrammed to a lower pulse width in all of the patients. This permitted a substantial prolongation of the pulse generator life. The cost effectiveness of the pulse generator was also greatly improved by pacing with reduced pulse widths. In an additional 16 patients, the voltage amplitude was reduced from 5.0 volts to 2.5 volts. This permitted an even greater increase in the pulse generator longevity.

Right bundle branch block: a rare manifestation of digitalis toxicity--case report

A case of intermittent right bundle branch block due to digoxin intoxication is presented. The diagnosis was made by repeated electrocardiograms and elevated serum digoxin levels. The mechanism of intermittent right bundle branch block is discussed and the pertinent literature is reviewed.

Determination of kanamycin concentration in serum by substrate-labeled fluorescent immunoassay

A homogeneous substrate-labeled fluorescent immunoassay was developed for the measurement of kanamycin concentrations in serum. A fluorogenic drug reagent (FDR) (beta-galactosyl-umbelliferone-tobramycin) was prepared that is nonfluorescent under the conditions of the assay but is hydrolyzed upon catalysis by beta-galactosidase to yield a fluorescent product. Binding of the FDR to the antiserum to kanamycin prevented enzyme hydrolysis. The fixed level of FDR in the assay competed with kanamycin in the sample for a limited number of antibody-binding sites. Unbound FDR was hydrolyzed by beta-galactosidase to release a fluorescent product that is proportional to the kanamycin concentration in the sample. The assay exhibited good sensitivity, precision, and accuracy and correlated well with other methods.

Prospective testing of a scoring system designed to improve case selection for upper gastrointestinal investigation

A recently described scoring system designed to assess the individual risk of finding serious pathology in patients referred for upper gastrointestinal investigation has been prospectively tested in 1279 patients undergoing first-time endoscopy and 321 patients undergoing radiologic examination. The scoring system has been confirmed to give a reasonable prediction of the likelihood of finding serious pathology in two hospitals with differing endoscopic practice, and also to be applicable to patients attending for radiology. The system works best at defining a low-risk group (score less than 412, 26% of total) in which the incidence of serious pathology was 3%. All cases of malignancy (n = 55) occurred in patients scoring greater than 464 (50% of total). A simple table is described that allows for the easy calculation of score at a glance without the use of a computer. We believe that this scoring system, which can be implemented in seconds, is the simplest yet described and that it could prove to be a useful educational aid.

Acute complications of pulmonary artery catheter insertion in critically ill patients

Of 142 critically ill patients undergoing pulmonary artery catheter (PAC) insertion, 1.4% suffered pneumothorax and 7.7% experienced arterial puncture during central venous access. Catheterization was successful in all cases; however, 8.4% of patients required special maneuvers for pulmonary artery cannulation. The 52.3% incidence of cardiac arrhythmias during PAC insertion was primarily due to ventricular arrhythmia (VA), which was more common among patients with complicated myocardial infarction (p less than .01) and less common in patients with sepsis (p less than .05). The development of VA was significantly related to the duration of PAC insertion. Our study suggests that PAC placement carries certain risks and complications which should be weighed against the advantages of a PAC in each patient.

An unusual case of X-15 translocation: evidence for the presence of an 'activator' region on Xpter of man

A case of an X-autosome rearrangement is presented in which part of the Xpter is deleted but the STS and MIC2X loci are retained. The normal X is late replicating in 97/100 lymphocytes and 50/50 fibroblasts examined. It is assumed that the initial X-inactivation in the embryo is random, but that cells with the rearranged X inactivated are selected against because inactivation spreads into the attached autosomal segment. This spreading, through the normally active STS locus, is hypothesised to be caused by deletion of a part of Xpter which is critical for the maintenance of activity of the Xpter region as a whole.

Effect of oral alcohol on left ventricular ejection fraction, volumes, and segmental wall motion in normals and in patients with recent myocardial infarction

A first-pass nuclear angiogram and a multiple-gated acquisition study were obtained in 10 normal physicians and in 10 patients with a 7-to-10 day old transmural myocardial infarction. After the scan the subjects drank 2 oz. of whiskey. After 60 minutes, the multiple-gated acquisition study was repeated. In the normal group the left ventricular ejection fraction was 68% before and 72% after alcohol. The left ventricular end-diastolic volume increased from 89 to 97 ml while the left ventricular end-systolic volume decreased from 29 to 27 ml. The stroke volume rose from 61 to 70 ml/beat (p less than 0.05). The cardiac output increased from 4.0 to 5.0 l/min (p less than 0.05). In the infarction group, the left ventricular ejection fraction was 58% before and 56% after alcohol administration. The left ventricular end-diastolic volume fell from 111 to 96 ml, while the left ventricular end-systolic volume declined from 50 to 44 ml. The stroke volume fell from 61 to 52 ml/beat, while the cardiac output fell from 4.5 to 3.8 l/min. In the left ventricular infarction zones, alcohol produced in 9 of the 10 cardiac patients a decline in the left ventricular regional ejection fraction. In the normal group, alcohol produced no significant changes in the regional ejection fraction. The normal and the postinfarction patients responded differently to alcohol.

The value of screening for autoantibodies in patients with non-specific symptoms

An autoantibody screen is often requested in patients with non-specific symptoms such as pyrexia of unknown origin. However, in a survey of 100 consecutive requests for this investigation in such patients only one patient was encountered in whom the investigation led to a positive diagnosis at an estimated cost of pound 2500. These requests accounted for 5% of the total workload. These observations reaffirm that this should remain a second line investigation and should be deferred until more likely diagnoses have been excluded.

Trial of relaxation in reducing coronary risk: four year follow up

On screening 192 men and women aged 35-64 were identified as having two or more of the following risk factors: blood pressure greater than or equal to 140/90 mm Hg, plasma cholesterol concentration greater than or equal to 6.3 mmol/l (243.6 mg/100 ml), and current smoking habit greater than or equal to 10 cigarettes a day. They were randomly allocated to a group for modification of behaviour or to serve as controls. Both groups were given health education leaflets containing advice to stop smoking, to reduce animal fats in the diet, and on the importance of reducing blood pressure. In addition, the treatment group had group sessions of one hour a week for eight weeks in which they were taught breathing exercises, relaxation, and meditation and about managing stress. It had previously been found that after eight weeks and eight months there was a significantly greater reduction in both systolic and diastolic blood pressures in the group taught to relax compared with the control group. After four years of follow up these differences in blood pressure were maintained. Plasma cholesterol concentration and the number of cigarettes smoked were lower in the treatment group at eight weeks and eight months but not at the four year follow up. At four years more subjects in the control group reported having had angina and treatment for hypertension and its complications. Incidence of ischaemic heart disease, fatal myocardial infarction, or electrocardiographic evidence of ischaemia was significantly greater in the control group. If the results of this study could be obtained in a larger study the financial and health care implications would be enormous.

The Osborn wave in hypothermia

A patient is reported who presented with fatal hypothermia. The electrocardiographic changes of a sinus bradycardia, prolonged QT interval and Osborn waves were documented and correlated with body temperature. The possible genesis of these electrocardiographic changes is reviewed in this article.

Immunology of inflammatory bowel disease

Although the aetiology of ulcerative colitis and Crohn's disease remain unknown, immunological effector mechanisms become activated within the inflamed mucosa and may be responsible for the pathogenesis of chronic disease. There is an increased production of immunoglobulin within the mucosa, some of which has specificity for bacterial antigens, and complement activation occurs during exacerbation of the disease. Lymphocytes isolated from peripheral blood, or from the intestinal mucosa, are cytotoxic to colonic epithelial cells in vitro; a reaction which can be modulated by serum factors and bacterial antigens. Within the mucosa, there are increased populations of T lymphocytes although there is no change in the ratio of helper- to suppressor-cells as defined by phenotype. Studies of immunoregulatory control have shown that there may be alterations in the modulation of the local immune response, especially during active disease, although it is not clear whether these changes are primary or merely secondary to inflammation. It is posulated that many of the humoral and cellular responses to gut-associated antigens occur as a result of increased antigen absorption, increased presentation of antigen to the immune system due to the expression of Class II antigens by the inflamed epithelium and altered immuno-regulatory control.