Sudden death in hydrocephalic spina bifida aperta patients

Twelve patients of 146 hydrocephalic spina bifida aperta patients, treated with a ventricular drainage system, died suddenly. In 7 of them the cause of death was most probably related to the use of a ventriculovascular shunt, causing pulmonary embolism. Thromboembolic complications were not seen in the 26 hydrocephalic spina bifida patients treated with a ventriculoperitoneal shunt. In 4 other patients shunt malfunction was considered as the cause of sudden death. The case reports of these 11 patients are presented. Pathophysiological mechanisms are discussed and measures for prevention of these two potentially lethal complications are described.

Cytomegalovirus but not human T lymphotropic virus type III/lymphadenopathy associated virus detected by in situ hybridisation in retinal lesions in patients with the acquired immune deficiency syndrome

Paraffin sections of retinal tissue from five patients who died from the acquired immune deficiency syndrome (AIDS) and retinopathy were examined by in situ hybridisation experiments with deoxyribonucleic acid (DNA) labelled with sulphur-35 of lentivirus, human T lymphotropic virus type III/lymphadenopathy associated virus (HTLV-III/LAV), and cytomegalovirus. HTLV-III/LAV ribonucleic acid (RNA) was not detected in any of the tissue sections. Cytomegalovirus RNA was identified, however, in three of the five patients. Retinopathy induced by cytomegalovirus may thus be one of the many syndromes potentiated by the immunosuppression caused by HTLV-III/LAV.

Percutaneous transluminal balloon angioplasty in restenosis of coarctation of the aorta

Percutaneous transluminal balloon angioplasty was performed in five children with coarctation restenosis. After angioplasty the pressure gradient had decreased considerably in four patients. In all patients aortography showed an increase in the diameter of the lumen at the site of the restenosis. All patients were normotensive the day after angioplasty. There were no complications during or after the procedure.

Evolution of the Ratio of Strontium-87 to Strontium-86 in Seawater from Cretaceous to Present

A detailed record of the strontium-87 to strontium-86 ratio in seawater during the last 100 million years was determined by measuring this ratio in 137 well-preserved and well-dated fossil foraminifera samples. Sample preservation was evaluated from scanning electron microscopy studies, measured strontium-calcium ratios, and pore water strontium isotope ratios. The evolution of the strontium isotopic ratio in seawater offers a means to evaluate long-term changes in the global strontium isotope mass balance. Results show that the marine strontium isotope composition can be used for correlating and dating well-preserved authigenic marine sediments throughout much of the Cenozoic to a precision of +/-1 million years. The strontium-87 to strontium-86 ratio in seawater increased sharply across the Cretaceous/Tertiary boundary, but this feature is not readily explained as strontium input from a bolide impact on land.

Immunohistochemical localization of epidermal growth factor in rat and man

Epidermal growth factor (EGF) is a peptide which stimulates cell mitotic activity and differentiation, has a cytoprotective effect on the gastroduodenal mucosa, and inhibits gastric acid secretion. The immunohistochemical localization of EGF in the Brunner's glands and the submandibular glands is well documented. The localization of EGF in other tissues is still unclarified. In the present study, the immunohistochemical localization of EGF in tissues from rat, man and a 20 week human fetus were investigated. In man and rat, immunoreaction was found in the submandibular glands, the serous glands of the nasal cavity, Brunner's glands of the duodenum, the Paneth cells of the small intestine, and the tubular cells of the kidney. In the fetus EGF was found in the kidney and in the intestinal Paneth cells. Antisera raised against rat submandibular EGF did not recognize EGF in human tissues, whereas antisera against human urinary EGF worked in rat as well as man. EGF was found only in cells with an exocrine function.

Characterization of an unique RNA initiated immediately upstream from human alpha 1 globin gene in vivo and in vitro: polymerase II-dependence, tissue specificity, and subcellular location

We have identified an abundant transcript initiated upstream from the canonical cap site of human alpha 1 globin gene in bone marrow cells and in COS-7 cells transfected with an alpha 1 globin gene-containing plasmid. Similar to the major alpha 1 globin transcript, this upstream RNA is present almost exclusively in the cytoplasm of the transfected COS-7 cells. It is also synthesized efficiently in vitro by RNA polymerase II in the nuclear extracts prepared from a Hela cell line and an erythroleukemia cell line, K562. RNAs isolated from these cell lines, however, do not contain this upstream transcript. The putative 5' end of the alpha 1 globin upstream RNA is mapped by primer extension to base -45, which is located in between the CCAAT and TATA boxes. The synthesis of this RNA in vitro and in vivo, and the close proximity of its 5' end to the promoter of the alpha 1 globin gene suggest a common mechanism regulating the transcriptional initiation of both the upstream and the major alpha 1 globin RNAs.

Blood-brain barrier and peptides

The brain is both the source and the recipient of peptide signals. The question is: Do endogenous, blood-borne peptide molecules influence brain function? Brain regions with the tight capillaries of the blood-brain barrier (BBB) extract low but measurable amounts of labeled peptide molecules from an intracarotid bolus injection. In the rat, the extraction fractions of beta-casomorphin-5, DesGlyNH2-arginine-vasopressin, arginine-vasopressin, lysine-vasopressin, oxytocin, gonadoliberin, substance P, and beta-endorphin, studied in this laboratory, range from 0.5% (substance P) to 2.4% (arginine-vasopressin). Extraction varies little among the 15 examined brain regions. As shown for arginine-vasopressin, the extracted peptides may be bound in part to specific binding sites located on the luminal membrane of the tight endothelial cells. Transport of peptide molecules across the BBB cannot be ruled out, but it is unlikely that endogenous peptides pass the BBB in physiologically significant amounts. In contrast, in brain regions with leaky capillaries, e.g., selected circumventricular organs including the pineal gland, neurohypophysis, and choroid plexus, the peptide fraction extracted approaches that of water. Within the circumventricular organs, the peptide molecules actually reach the cellular elements of the tissue. However, no studies definitively show that peptides reach neurons in the deeper layers of the brain. On the other hand, blood-borne peptides influence the BBB permeability by altering the transport of essential substances. The effect may be mediated by specific peptide binding sites located at the luminal membrane of the endothelium. It is possible that the effect of peptides on the BBB is necessary for proper brain function.(ABSTRACT TRUNCATED AT 250 WORDS)

Managing hospital census through physician/administrator teamwork

This article describes the process of successful implementation of a system to manage and control a hospital's inpatient census. The system has implications not only for every department, but for every profession within a hospital environment. Described here is the overall impact of the system within a hospital. Also presented are important factors which have contributed to the success of implementation in this complex setting.

Generalised Coxsackie A9 infection in a neonate presenting with pericarditis

Coxsackie A9 virus was isolated from a neonate presenting with a massive pericardial effusion. Delivery had occurred after maternal infection. The virus was cultured from the cerebrospinal fluid, urine, and faeces of the infant and from the faeces of the mother and a sibling. Despite signs of generalised infection with pericarditis, meningitis, pneumonitis, and hepatitis, recovery was complete.

Protein-losing enteropathy after Fontan operation

Generalized edema resulting from severe protein-losing enteropathy occurred in three patients 12, 15, and 17 months after the Fontan operation. One patient originally had tricuspid atresia and the other two, univentricular heart disease. At operation a conduit had been inserted between the right atrium and pulmonary artery. Apart from the protein loss, the patients were in good health. The cardiac catheterization data obtained 0.8 to 2.4 years (median 1.3 years) after operation in the three patients with protein-losing enteropathy were compared with those of 18 patients in whom Fontan's operation had been performed because of tricuspid atresia (eight patients) or univentricular heart disease (10 patients). All had atriopulmonary connections. The mean right and left atrial pressures and systemic blood flows measured by dye dilution in the patients with and without protein-losing enteropathy did not differ. However, the patients with protein-losing enteropathy had a higher diastolic right atrial pressure. Since maximal antegrade flow in the superior vena cava after Fontan's operation occurs during atrial diastole, these observations suggest that an increase in diastolic right atrial pressure may result in protein-losing enteropathy because of impairment of blood flow and therefore congestion in the superior vena cava, subclavian vein, and thoracic duct.

Left ventricle descending aorta valved conduit to relieve congenital aortic stenosis in children

A valved conduit was inserted between the apex of the left ventricle and the descending aorta in 2 patients, 4 months and 10 years of age, respectively, who had valvular aortic stenosis. The development of both patients has been excellent since operation. At control catheterization (1 and 2 years postoperatively) no pressure gradient was found between the left ventricle and the aorta. In both patients the aortic valve area showed growth to near normal size on echocardiographic study 3 years postoperatively.

A randomized double-blind investigation of cefroxadine (CGP 9000) versus cephalexin in urinary tract infection

A total of 64 out-patients with significant urinary tract infection were randomly allocated to treatment with cefroxadine 250 mg q.i.d. or cephalexin 500 mg q.i.d. for ten days. Urine cultures were performed before allocation to the treatment groups and on Days 0, 1, 3, 7 and 21. Twenty patients discontinued treatment prematurely because of insignificant bacteriuria on Day 0. Both drug regimes--the cefroxadine dose was half that of cephalexin--showed good activity during treatment, and no statistically significant differences were found between the two drugs. At follow-up, several relapses were found in both treatment groups. Adverse drug reactions were only reported by three patients in the cefroxadine group, and by none in the cephalexin group.

[Myocardial infarct in a newborn infant]

Myocardial infarction is rarely described in the newborn. We report a case in which the newborn had a normal heart and probably normal coronary arteries. The only presenting sign was transient extrasystolic beats. The course was uneventful and our patient recovered spontaneously. A review of the literature is presented.

Lack of neutralizing antibodies to caprine arthritis-encephalitis lentivirus in persistently infected goats can be overcome by immunization with inactivated Mycobacterium tuberculosis

The pathogenesis of the persistent progressive diseases of sheep (visna-maedi) and goats (arthritis-encephalitis) is dependent on continuous replication of the causative lentiviruses. One subgroup of these viruses, Icelandic visna virus, accomplishes this form of replication by undergoing antigenic mutation. Mutant viruses arising late in the infection escape neutralization by antibodies directed to the parental virus. In contrast, we show here that viruses obtained from persistently infected sheep and goats with natural disease in this country do not induce virus-neutralizing antibodies, although antibodies to virus core proteins were produced. The lack of neutralizing antibodies was not overcome by hyperimmunization of animals with concentrated preparations of live or inactivated virus. Thus, failure to produce these specific antibodies was not due to lack of sufficient antigen or interference with the immune response because of the ability of these viruses to infect macrophages. The hyporesponsive state, however, was overcome by immunization of animals with virus and large amounts of inactivated Mycobacterium tuberculosis. Induction of agglutinating and neutralizing antibodies by this method was probably due to a unique form of antigen processing by macrophages activated by M. tuberculosis. Neutralizing antibodies were produced for the first time against the caprine arthritis-encephalitis virus by this method. These antibodies have similar biological properties to those induced by Icelandic visna virus. They belong to the immunoglobulin G1 subclass, they are effective against a narrow range of caprine arthritis-encephalitis viruses, and they identify (for the first time) antigenic variants among these caprine agents.

[Biocompatibility of implants with and without fluorohydrocarbon glow-discharge polymer coating. 1. Histologic and semiquantitative estimation of subcutaneous reactions in guinea pigs]

The reaction of the subcutaneous tissue in guinea-pigs at implants of titanium, titanium/glow discharge polymer, Gisadent KCM (chromium cobalt molybdenum alloy), and Gisadent/glow discharge polymer was investigated by a semiquantitative method of informing character. The 4 tested materials were well-tolerated at which titanium caused the smallest reaction.

Significance of penicillin tolerance in vivo: prevention of experimental Streptococcus sanguis endocarditis

To determine whether in-vitro tolerance to penicillin among viridans streptococci influences the efficacy of penicillin in vivo, we studied four strains of dextran-producing. Streptococcus sanguis serotype II. All four strains were inhibited in vitro by 0.1 mg/l penicillin or less; one was not-tolerant, one intermediate, and two were tolerant to the lethal action of penicillin. The combination of penicillin and streptomycin killed all strains completely within 24 h in vitro. Sera from rabbits injected with penicillin were inhibitory for all strains, but were bactericidal only for the non-tolerant strain. The incidence of endocarditis in untreated rabbits with left heart catheters was 100% after inoculation of each of the four strains. Despite attempted prophylaxis with procaine penicillin G, endocarditis developed in 44 of 70 rabbits (63%) injected with the tolerant strains, contrasting with 2 of 22 (9%) for the non-tolerant strain (P=0.0001). The probability that penicillin would fail to prevent endocarditis was directly related to its minimal bactericidal concentration for each strain (r=0.95). In contrast, the combination of penicillin plus streptomycin always prevented endocarditis. We conclude that penicillin tolerance can be a crucial determinant of the response of viridans streptococci to penicillin in vivo.

Incidence of postextraction bacteremia under penicillin cover in children with cardiac disease

To assess the efficacy of penicillin prophylaxis as recommended by the American Heart Association to prevent the onset of bacterial endocarditis, the incidence of postextraction bacteremia was determined in 82 children with cardiac disease who were receiving prophylactic penicillin. Aerobic and anaerobic blood cultures were taken five minutes after dental extraction, as was a blood sample to assay the serum penicillin concentration. The incidence of postextraction bacteremia was 21%. Streptococcal species accounted for half of the number of aerobes isolated. Of the isolated microorganisms, 16% were strict anaerobes. Susceptibility testing of the isolates showed that 24 penicillin-sensitive and eight penicillin-resistant microorganisms caused the bacteremia. There was neither a significant difference between the serum penicillin concentrations of children with and without bacteremia, nor between the serum penicillin concentrations of children with bacteremia due to penicillin-sensitive microorganisms and children with bacteremia due to penicillin-resistant microorganisms. It is concluded that the occurrence of postextraction bacteremia is not prevented by penicillin prophylaxis and that the serum penicillin concentration at extraction is not the discriminating factor in preventing this bacteremia. None of the children developed bacterial endocarditis. It is speculated that mechanisms not thoroughly studied are involved in the prevention of bacterial endocarditis after dental extraction.

Importance of minimizing carry-over effect at subculture in the detection of penicillin-tolerant viridans group streptococci

Penicillin susceptibility determinations made for 14 strains of Streptococcus mitior by two different broth dilution tests revealed small numbers of tolerant strains regardless of the volumes (0.01 and 0.1 ml) of subcultured broth. The addition of penicillinase to the subculture medium increased the number of tolerant strains significantly in 0.1 ml of subcultured broth, demonstrating that the detection of penicillin-tolerant viridans group streptococci might be hampered by the carry-over of penicillin.

Penicillin Prophylaxis in Children with Cardiac Disease: Postextraction Bacteremia and Penicillin-Resistant Strains of Viridans Streptococci

The incidence of postextraction bacteremia in 82 children with dental foci and cardiac disease given parenteral penicillin prophylaxis was assessed 5 min after extraction. Penicillin concentrations were determined in blood samples obtained at the same time. Before extraction, cultures were taken from the gingival sulcus. Postextraction bacteremia occurred in 21% of the patients and was due to penicillin-sensitive microorganisms in 10 and to both penicillin-sensitive and penicillin-resistant microorganisms in seven children. In three of these children penicillin-resistant viridans streptococcal strains were isolated. Penicillin-resistant viridans streptococci were present in the gingival sulcus flora of 39% of the children, but a relationship between the presence of such strains in the gingival sulcus and the occurrence of postextraction bacteremia could not be demonstrated. There was no difference in the serum penicillin concentrations found in children with bacteremia due to penicillin-sensitive or penicillin-resistant microorganisms, or between the concentrations in children with and without bacteremia.

Serum estriol level during treatment with betamethasone in the last trimester of human pregnancy

A comparison was made between betamethasone disodiumphosphate/betamethasone acetate (Celeston) and betamethasone disodiumphosphate (Celestona) in antenatally prophylactic treatment of respiratory distress syndrome syndrome (RDS). Altogether 65 pregnant women in the last trimester of pregnancy were treated with the first-mentioned drug and 62 with the second. The RDS-preventive effect was the same in the two groups. Celeston has a much longer depressive effect on the level of plasma estriol than has Celestona. Use of this drug, betamethasone disodiumphosphate, is therefore recommended in the prophylaxis against RDS.

Occipitofrontal circumference in newborns of betamethasone treated mothers

Celestona (betamethasone-disodiumphosphate) and Celeston (betamethasone-acetat + betamethasone-disodiumphosphate) given intramuscularly to pregnant women in order to reduce the frequency of respiratory distress syndrome does not reduce the occipitofrontal circumference of the newborn infants. Before the results from the actual work were available an impeding effect of the evolution of the brain was found in the light of animal experiments. The material is comprised of 52 newborn infants whose mothers were treated with Celestona 8 mg daily for 3 days and 46 infants treated with Celeston 12 mg daily for 3 days. The untreated population comprises 1012 newborn infants. Excluded were non-caucasian infants, twins, stillborns and cases of uncertain gestational age. The occipitofrontal circumference in normal infants and those infants treated with betamethasone were compared in Figs. 2 and 3. Focusing only upon cases in which corticoids were given more than 7 days before delivery and in which no placental dysfunction was diagnosed, no differences from the normal were found (Tabs. II and III, and Figs. 3 A and B).

Screening for penicillin tolerance in viridans streptococci by a simple disk method

A disk method was developed for demonstrating penicillin tolerance in viridans streptococci. This was achieved by the substitution of the penicillin disk used for susceptibility testing by a disk containing penicillinase. After reincubation, penicillin-tolerant strains exhibited new growth in the area adjacent to this disk, providing a rapid screening test.

Experiences with the Fontan operation

Up to December 1980 we performed 21 Fontan operations: 8 for tricuspid atresia and 13 for a functional monoventricle. Although palliative, the operation is currently a good method of treating tricuspid atresia. In our experience, the use of a sufficiently large atriopulmonary valved conduit assures a more satisfactory immediate postoperative hemodynamic result than the atriobulbar non-valved connection (RA-infund. tunnel). Good results can be obtained by a modified Fontan operation in patients with a monoventricle. However, with this malformation, very careful preoperative selection of patients is necessary with special regard to pulmonary vascular resistance. The connection between the right atrium and pulmonary artery was established by a valved conduit in 15 patients; no valve was incorporated in the other 6 patients. The largest prostheses gave the best immediate postoperative hemodynamic results. Two patients with monoventricle were successfully reoperated for persistent right-left shunt. The 13 patients so far followed up for at least a year show definite improvement as compared with their preoperative condition. Late complications from the valved prostheses have not been observed so far.

Successful management of cor triatriatum associated with anomalous pulmonary/systemic venous connection in an infant

Diagnosis and successful surgical repair of cor triatriatum, associated with anomalous pulmonary/systemic venous connection in a 6-month-old infant, is described. Follow-up at 2 years revealed no abnormalities. The clinical findings, hemodynamics, and surgical treatment are discussed, together with a review of the literature. This is a rare, life-threatening situation presenting significant diagnostic difficulties in infancy. It is, however, amenable to surgery provided that an early diagnosis is achieved.

Mycotic aneurysm at site of formerly ligated ductus arteriosus caused by infective endarteritis

Images

Pulmonary atelectasis following upper urinary tract surgery on patients in the 25 degrees and 45 degrees 'jack-knife' position. A sequential analysis

The development of pulmonary atelectasis following upper urinary tract surgery in patients positioned either in the 25 degrees or the 45 degrees 'jack-knife' position was evaluated in a randomized clinical trial with sequential analysis. Atelectasis was diagnosed from chest radiographs and/or from a decrease in arterial oxygen tension during the first three postoperative days. 32.1% of 78 patients developed atelectasis, but no statistically significant differences was found between the two positions.

Indications for a brain uptake of labelled vasopressin and ocytocin and the problem of the blood-brain barrier

Fifteen seconds after intracarotid injection of [125J]-lysine vasopressin, [3H]-ocytocin, tritiated water or [3H]-inulin, the distribution of radioactivity in 18 regions of the rat brain and in the anterior pituitary was determined. Comparing the concentration of the different tracers (in % of injected radioactivity per g brain tissue), it is assumed that a small amount of the labelled neurohormones is taken up by the brain, indicating a penetration of the blood-brain barrier and/or an accumulation within the structures of the barrier system.