Chronic tophaceous gout. A case report

A review of gout is presented, followed by a discussion of the current medical literature on diagnosis, differential diagnosis, staging, and treatment. Chronic tophaceous gout is not as prevalent as it once was because of early diagnosis and treatment, but it is still encountered in the podiatric practice. A severe case of chronic tophaceous gout is presented. The patient was successfully treated by surgical intervention. Although surgery may be avoided in most cases, it is indicated when intractable pain, loss of motion, and massive joint destruction are present.

[Psychotherapy of loss and grief]

For many years, survivors of the Holocaust in Israel and elsewhere have made little space in their lives for past memories. Indeed, they feared being overcome by them and influencing their children negatively as a result. When these people reach the age of putting their whole life into perspective, the mourning and loss processes are reactivated by the need to hold testimony. Also, they seek to be part of the continuity of crucial events that marked their past, particularly concerning the separation from their family of origin, network of friends and cultural community. Furthermore, since people belonging to the second generation grew up with this separation from family roots, they would develop fantasies often linked to a somewhat guilty complex. The authors present two clinical cases to illustrate each of the two themes in the article.

Effects of prolonged mental work on functional brain topography

Topographic patterns of event-related covariance between electrodes were measured from subjects performing a difficult memory and fine-motor control task for 10-14 h. Striking changes occurred in the patterns after subjects performed the task for an average of 7-9 h, but before performance deteriorated. Pattern strength was reduced in a fraction-of-a-second-long response preparation interval over midline precentral areas and over the entire left hemisphere. By contrast, pattern strength in a succeeding response inhibition interval was reduced over all areas. The pattern changed least in an intervening interval associated with visual-stimulus processing. This suggests that, in addition to the well-known global reduction in neuroelectric signal strength, functional neural networks are selectively affected by sustained mental work in specific fraction-of-a-second task intervals.

N-(3,5-dichlorophenyl)succinimide nephrotoxicity in streptozotocin-induced diabetic rats

N-(3,5-Dichlorophenyl)succinimide (NDPS) is an experimental fungicide which induces renal toxicity. The following study examined the nephrotoxicity induced by NDPS in streptozotocin (STZ) diabetic rats. Male Fischer 344 (F344) rats were injected with 35 mg/kg STZ (i.p.) or citrate buffer. Fourteen days after STZ or citrate buffer injection, the rats (4-6 rats/group) were injected with (0.4 or 1.0 mmol/kg) NDPS or vehicle (sesame oil, 2.5 ml/kg). Kidney weight, blood urea nitrogen (BUN) levels, morphology and renal cortical slice uptake of organic ions was quantitated 48 h after NDPS administration. A 0.4 mmol/kg dose of NDPS induced diuresis, increased kidney weight and a moderate elevation in BUN levels in the normoglycemic group. The 1.0 mmol/kg dose of NDPS produced diuresis, proteinuria, increased kidney weight and a marked increase in BUN levels in the normoglycemic group. The renal cortical slice uptake of p-aminohippurate (PAH) and tetraethylammonium (TEA) was also decreased 48 h after NDPS injection in the normoglycemic group. No alterations in kidney weight, BUN levels, morphology or renal cortical slice uptake of organic ions was observed in the diabetic animals treated with (0.4 or 1.0 mmol/kg) NDPS. The results of this study indicate that the renal toxicity of NDPS was reduced in the diabetic rat.

Glutathione turnover in cultured astrocytes: studies with [15N]glutamate

The incorporation of [15N]glutamic acid into glutathione was studied in primary cultures of astrocytes. Turnover of the intracellular glutathione pool was rapid, attaining a steady state value of 30.0 atom% excess in 180 min. The intracellular glutathione concentration was high (20-40 nmol/mg protein) and the tripeptide was released rapidly into the incubation medium. Although labeling of glutathione (atom% excess) with [15N]glutamate occurred rapidly, little accumulation of 15N in glutathione was noted during the incubation compared with 15N in aspartate, glutamine, and alanine. Glutathione turnover was stimulated by incubating the astrocytes with diethylmaleate, an electrophile that caused a partial depletion of the glutathione pool(s). Diethylmaleate treatment also was associated with significant reductions of intraastrocytic glutamate, glycine, and cysteine, i.e., the constituents of glutathione. Glutathione synthesis could be stimulated by supplementing the steady-state incubation medium with 0.05 mM L-cysteine, such treatment again partially depleting intraastrocytic glutamate and causing significant reductions of 15N labeling of both alanine and glutamine, suggesting that glutamate had been diverted from the synthesis of these amino acids and toward the formation of glutathione. The current study underscores both the intensity of glutathione turnover in astrocytes and the relationship of this turnover to the metabolism of glutamate and other amino acids.

Clinical assessment of treatments for prolonged bleeding in users of Norplant implants

The effectiveness of three drugs in controlling prolonged bleeding in the first year of NORPLANT implants use was tested. The drugs were levonorgestrel (L-Ng, 0.03 mg twice a day for 20 days), ethinylestradiol (EE, 0.05 mg per day for 20 days) and ibuprofen (Ib, 800 mg three times a day for 5 days) and were given orally. A control group received a placebo (PL, one pill of lactose for 20 days). Treatment should start each time a woman experienced eight consecutive days of bleeding or spotting. The 183 volunteers were not aware of the drug administered. A daily record of bleeding and spotting and of treatment intake was maintained. One-hundred-forty women completed the study period; 60 never used the prescribed treatment. Women treated with the three test drugs had significantly fewer bleeding and spotting days during the treated month and also throughout the study year than women using the placebo. The mean number of bleeding plus spotting days per actually treated subject in the first year was 77, 94, 101 and 129 days for the EE, Ib, L-Ng and PL groups, respectively. The administration of EE might help in the management of prolonged bleeding during the first year of NORPLANT implants use.

Pelvic sonography can predict ovum release in gonadotrophin-treated patients as determined by pregnancy rate

Ultrasonographic monitoring of ovum release was performed in two consecutive cycles in each of 220 patients treated with gonadotrophin. Definite release occurred in 69% of cycles, indeterminate in 24% and non-release in 7%. Support for the accuracy of sonography in diagnosing the luteinized unruptured follicle (LUF) was demonstrated by a much higher pregnancy rate in those patients showing ovum release. There was a definite tendency for non-release to recur in the next cycle. Thus, the data support the routine use of sonography 2-3 days after human chorionic gonadotrophin (HCG) injection to monitor ovum release in gonadotrophin-treated patients (HMG).

Synthesis of positively charged phthalocyanines and their activity in the photodynamic therapy of cancer cells

Positively charged zinc containing or metal free phthalocyanines 6a-c and 7a-c were prepared via a three step procedure starting from 4-nitrophthalonitrile. The phthalocyanines contain alkyl chains of different length in order to influence the hydrophilic vs lipophilic character of the compounds. The partition between a hydrophilic (water) and lipophilic (octanol-1) phase was determined, and the photoredox activities were investigated. Initial results on the photodynamic activity of these compounds were compared with those of Dougherty's Photofrin II on different malignant and non-malignant cell lines (XP 29MAmal, CX1, HeLa, S180 and NO17). Positively charged phthalocyanines in vitro showed a higher photodynamic activity than Photofrin II.

Intact parathyroid hormone in primary hyperparathyroidism

In 49 patients with primary hyperparathyroidism, intact parathyroid hormone (PTH) was measured with a recently developed immunoradiometric assay, and midregional PTH fragments (sequence 44-68) were measured with an established radioimmunoassay technique. In 47 normal subjects, the concentration of intact PTH ranged from 2.0 to 6.8 pmol/l, and in 49 patients with primary hyperparathyroidism it ranged from 6.4 to 80.0 pmol/l. In contrast, midregional PTH fragments were normal in seven of 49 patients with primary hyperparathyroidism. In five healthy controls and in 12 patients with surgically confirmed primary hyperparathyroidism and serum calcium levels below 3.0 mmol/l, a rapid calcium loading test was performed. In healthy controls, intact PTH was in the low normal to subnormal range within 2.5-5.0 min, and had recovered within 15 min of calcium infusion. In patients with primary hyperparathyroidism, the calcium infusion also led to a 30-50 per cent decrease in intact PTH levels within 5.0-7.5 min after injection, with a slow recovery after 10-15 min. In six of the patients with only slightly elevated basal intact PTH, a suppression to the normal range was observed. In 24 patients (16 patients with a solitary adenoma and eight patients with four-gland hyperplasia) the intact PTH levels were followed intraoperatively during parathyroidectomy, revealing a significantly different rate of decline for single adenomas compared with hyperplasia during the first 15 min after removal of the primary enlarged gland. Intact PTH values remained constantly elevated in one patient with primary hyperparathyroidism and an unsuccessful neck exploration. These results confirm that (a) the measurement of intact PTH in patients with primary hyperparathyroidism is superior to the measurement of midregional fragments; (b) PTH secretion in primary hyperparathyroidism is not totally autonomous; and (c) intraoperative monitoring of intact PTH values could be used to monitor the success of surgery.

Regional differences in norepinephrine and dopamine concentration and effect on serotonin uptake and release in bovine pineal gland

In order to analyze whether the bovine pineal gland is a homogeneous or a heterogeneous structure as far as monoamine content, the regional differences in norepinephrine (NE), dopamine (DA), serotonin (5HT), and 5-hydroxyindoleacetic acid (5HIAA) contents were assessed by high-pressure liquid chromatography. NE content was maximal in the proximal (close to the recessus pinealis) region and decreased in a rostral-caudal direction to achieve minimal values at the distal region. DA exhibited an opposite trend to NE, NE/DA ratios varying from 3.2 (proximal region) to 1.4 (distal region). Significantly lower NE content was found at the inferior as compared to the superior pineal region, and at the cortex as compared to the medulla. No significant differences were detected in DA concentration of these latter pineal regions, or in 5HT or 5HIAA concentration as a function of the region examined. 3H-5HT and 3H-NE uptake were maximal at the proximal zone in a rostral-caudal direction, at the superior as compared to the inferior region, and at the medulla as compared to the cortex. Unlabeled NE was equally effective to compete with 3H-5HT uptake in the several pineal regions studied. While NE increased maximally 3H-5HT release in a rostral-caudal direction, DA exhibited an opposite trend, displaying maximal 5HT release activity at the distal pineal region. DA and NE 5HT-releasing activity were greater in the pineal medulla than in the cortex, and did not exhibit differences in the superior as compared to the inferior pineal aspects. Excess (55 mM) K+ released 3H-5HT to a similar extent regardless of the pineal region examined.

Maternal brown fat metabolism returns to control level by four weeks postweaning in rats

We studied body composition, white and brown adipose tissue cellularity, lipoprotein lipase activity and metabolic enzyme activity in three groups of rats: nonpregnant controls, lactating dams and nonlactating dams (i.e., dams not permitted to suckle their young). Nine to 11 rats in each group were killed on d 12 postpartum (study d 34) and on d 40 postpartum (study d 62). During lactation, brown fat citrate synthase, beta-hydroxyacylCoA dehydrogenase (HOAD) and lipoprotein lipase activities were significantly lower in the lactating than in the nonlactating dams or virgin controls. Although the nonlactating dams had their pups removed within 24 h after delivery, by d 12 postpartum citrate synthase and HOAD activities were significantly lower than those of nonpregnant controls. By the end of the study there were no differences among the three groups except in the case of HOAD. HOAD activity in the lactation group was significantly lower than in the nonlactation group. White fat cell number in the parametrial depot was significantly increased in the nonlactation groups by d 12 postpartum. In the lactation group, increased white fat cell number in this depot was detectable at d 40 postpartum, when carcass fat stores and fat cells had been repleted. These results demonstrate that both lactating and nonlactating dams undergo cellular hyperplasia, at least in the parametrial depot. This may predispose them to obesity. Also, decreased brown fat metabolism in the nonlactating dams may be contributing to their significantly greater carcass fat content at d 12 postpartum.

Prediction of the left ventricular ejection fraction response to doxorubicin using a multiple linear regression model

The aim of this study was to develop a model for predicting clinically significant deterioration in the left ventricular ejection fraction due to chronic doxorubicin administration. Twenty-six patients were monitored during their courses of doxorubicin chemotherapy with serial gated equilibrium radionuclide angiography. Multiple linear regression analysis was used to derived the best combination of clinical and radionuclide angiographic predictors of resting left ventricular ejection fraction at any point during the course of chemotherapy. The final model consisted of five variables: left ventricular ejection fraction at the previous monitoring point; cumulative dose of doxorubicin achieved at the previous monitoring point; increment in dose from the previous monitoring point; age of the patient; and time to peak left ventricular emptying at the previous monitoring point. The cumulative dose, the ejection fraction at the previous monitoring point and the final model, respectively, explained 11%, 33% and 53% of the variability in ejection fraction determinations during the 26 patient courses. The final model also forecast a potentially very low resting left ventricular ejection fraction (less than 35%) at the cumulative doses of doxorubicin which provoked serious clinical cardiotoxicity in two patients. A multivariate model is a useful aid in timing discontinuation of doxorubicin prior to the development of a clinically significant deterioration in left ventricular ejection fraction.

Telephone versus face to face interviewing as a means of collecting data relevant to the management of diabetes among general practitioners in France: a randomized design

Successful patient education requires planed programs with specific target populations. As general practitioners see 85% of noninsulin-dependent diabetics in France, this study was designed to test the feasibility of the telephone as a method for data collection within the context of a random sample of general practitioners in the Paris region. In addition, data were collected assessing physician's perceptions of various barriers and facilitators to the management of this illness. The study demonstrated the feasibility of phone interviews among general practitioners, as no significant differences were found in response rates or for any single variable collected on the telephone versus "face-to-face". Treatment patterns were described and results indicated that 77% of general practitioners agreed to participate in a subsequent study and, of these 93% agreed to the participation of their noninsulin-dependent patients.

Effects of palmitate on astrocyte amino acid contents

The effects of palmitate on intracellular and extracellular amino acid concentrations of cultured astrocytes was studied. Exposure of astrocytes to either 0.72 mM or 0.36 mM palmitate was associated with a significant reduction in the intracellular pool of glutamine and taurine. In contrast, the intracellular concentration of histidine, glycine, citrulline, isoleucine and leucine were increased in the presence of 0.72 mM palmitate. Comparable changes in the extracellular amino acid pool were not observed. The data suggest that palmitic acid, which accumulates in the brain during periods of anoxia, alters the metabolism of several amino acids in cultured astrocytes. These changes may be of significance in terms of the pathophysiology of a stress such as anoxia.

[Small intestine pouches as a therapeutic principle in stomach and large intestine replacement]

Small bowel pouches are being utilized in several versions as substitute reservoirs after total gastrectomy and after continence preserving proctocolectomy. Throughout the world, most frequently the pouch is formed by simple duplication of the gut. The principles of reservoir formation, the special functional requirement in the upper and lower GI-tract are delineated. Follow-up studies prove the successful use of gastric and ileoanal pouches.

[Pathophysiology and technical prerequisites for maintaining continence]

Restoration of gastrointestinal continuity following total colectomy in patients with ulcerative colitis or familial polyposis can be achieved by construction of an ileal pouch and ileoanal anastomosis. In the development of the surgical technique three problems have emerged: a) pull-through operation; b) construction of the reservoir; c) anatomy and physiology of the sphincter system. The function of the continence organ can be evaluated by means of manometric, electromyographic and volumetric tests. The success of this complex surgical procedure also depends on the characteristics of the individual patient.