[Teratoma in the middle ear and throat of an infant]

The authors present a case of an 8-moth-old female infant treated for prolonged otitis media. The inflammatory process was connected with teratoma of tympanum and throat. The authors discuss presumable connection of the both masses. The child was completely cured by surgical treatment.

Genetic influences on baroreflex function in normal twins

Blood pressure and heart rate are strongly influenced by genetic factors; however, despite the pivotal role of genetics in short-term cardiovascular regulation, little is known about the genetic contribution to baroreflex function. We assessed genetic influence on baroreflex sensitivity (BRS) in 149 twin pairs (88 monozygotic of age 33+/-13 years and BMI 23+/-4 kg/m(2) and 61 dizygotic of age 33+/-11 years and BMI 24+/-4 kg/m(2)). ECG and finger arterial blood pressures were measured continuously under resting conditions. BRS values were calculated by use of cross-spectral analysis (baroreflex slope calculated as mean value of transfer function between systolic blood pressure and the R-R interval in the low-frequency band [BRSLF] and baroreflex slope calculated as the mean value of transfer function between systolic blood pressure and R-R interval in the respiratory frequency band [BRSHF]) and the sequence technique (BRS+, BRS-). Heritability (h(2)) was estimated with a path-modeling approach. BRS values did not differ significantly between groups (monozygotic, BRSLF, 17+/-13; BRSHF, 21+/-18; BRS+, 19+/-16; and BRS-, 21+/-15, and dizygotic, BRSLF, 16+/-9; BRSHF, 20+/-14; BRS+, 18+/-10; and BRS-, 20+/-11 ms/mm Hg), and were significantly correlated (P:<0.001). When variances and covariances for monozygotic and dizygotic twins were compared, significant correlations were found for BRS in monozygotic (range, r=0.38 to 0.48) but not in dizygotic twin pairs (r=-0.03 to 0.09). Thus, BRS is heritable; the variability can be explained by genetic influences (P:<0.01; h(2) range, 0.36 to 0.44). The genetic influence on BRS remained strong after correction for BMI and blood pressure. Therefore, BRS is strongly genetically determined, probably by different genes than are resting blood pressure and BMI.

[The results of salvage surgery in the patients with the laryngeal cancer after failed radiotherapy]

The authors present material of 50 patients suffered from laryngeal cancer, who had performed salvage laryngectomy after failure radiotherapy. Greatest influence on the results of treatment had local and regional advanced of cancer and immediately tracheotomy before laryngectomy. The performance oft total laryngectomy is advocated as a salvage treatment in the ceases of failed radiotherapy. The authors underline that performance of laryngectomy after obtaining of laryngeal cancer on the basis of histopathological examination in a number of cases delayed the surgical treatment and thus caused in some of them that the patient's chance to be cured was lost.

[Hemangioendothelioma of the larynx]

The authors present a case of 37 years old patient suffered from the laryngeal tumour, which was hemangioendothelioma. Recurrence was observed three times after surgically treatment. The difference between histopathological "benign" character and clinically "malignant" course is interested. The authors put attention on the difficulties with establish right management. Occurrence of the hemangioendothelioma in the larynx is very rare. The authors stressed the big difference in estimate of hemangioendothelioma malignancy presented in literature.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

[Double adenoid cystic and squamous cells carcinoma of the hypopharynx and larynx. A contribution to the issue of multicomponent neoplasms]

Bicomponent cancer of the piriform fossa and larynx of 55 years old man has been described. The patient was treated surgically and by radiotherapy. The performance of laryngectomy and partial pharyngectomy with conservative bilateral neck dissection was used as surgical treatment. In histopathological findings of postoperative specimens two types of neoplasms: squamous cells and adenoid-cystic cancers were stated. The authors presented opinions on the affection arising of multicomponent tumours of the aerodigestive truct.

Severely impaired baroreflex-buffering in patients with monogenic hypertension and neurovascular contact

BACKGROUND

We identified a family with a monogenic syndrome of hypertension, brachydactyly, and neurovascular contact of the brain stem. Neurovascular contact of the ventrolateral medulla may lead to arterial hypertension by interfering with baroreflex function.

METHODS AND RESULTS

In 5 patients with monogenic hypertension (18 to 34 years old), we conducted detailed autonomic function tests. Blood pressure during complete ganglionic blockade was 134+/-4.9/82+/-4.1 mm Hg and 90+/-6/49+/-2.4 mm Hg in patients and in control subjects, respectively. During ganglionic blockade, plasma vasopressin concentration increased 24-fold in control subjects and <2-fold in patients. In patients, cold pressor testing, hand-grip testing, and upright posture all increased blood pressure excessively. In contrast, muscle sympathetic nerve activity was not increased at rest or during cold pressor testing. The phenylephrine dose that increased systolic blood pressure 12.5 mm Hg was 8.0+/-2.0 microg in patients and 135+/-35 microg in control subjects before ganglionic blockade and 5.4+/-0.4 microg in patients and 13+/-4.8 microg in control subjects during ganglionic blockade.

CONCLUSIONS

In patients with monogenic hypertension and neurovascular contact, basal blood pressure was increased even during sympathetic and parasympathetic nerve traffic interruption. However, sympathetic stimuli caused an excessive increase in blood pressure. This excessive response cannot be explained by increased sympathetic nerve traffic or increased vascular sensitivity. Instead, we suggest that baroreflex buffering and baroreflex-mediated vasopressin release are severely impaired.

HDL-cholesterol-raising effect of orange juice in subjects with hypercholesterolemia

BACKGROUND

Orange juice-a rich source of vitamin C, folate, and flavonoids such as hesperidin-induces hypocholesterolemic responses in animals.

OBJECTIVE

We determined whether orange juice beneficially altered blood lipids in subjects with moderate hypercholesterolemia.

DESIGN

The sample consisted of 16 healthy men and 9 healthy women with elevated plasma total and LDL-cholesterol and normal plasma triacylglycerol concentrations. Participants incorporated 1, 2, or 3 cups (250 mL each) of orange juice sequentially into their diets, each dose over a period of 4 wk. This was followed by a 5-wk washout period. Plasma lipid, folate, homocyst(e)ine, and vitamin C (a compliance marker) concentrations were measured at baseline, after each treatment, and after the washout period.

RESULTS

Consumption of 750 mL but not of 250 or 500 mL orange juice daily increased HDL-cholesterol concentrations by 21% (P: < 0.001), triacylglycerol concentrations by 30% (from 1.56 +/- 0.72 to 2.03 +/- 0.91 mmol/L; P: < 0.02), and folate concentrations by 18% (P: < 0.01); decreased the LDL-HDL cholesterol ratio by 16% (P: < 0.005); and did not affect homocyst(e)ine concentrations. Plasma vitamin C concentrations increased significantly during each dietary period (2.1, 3.1, and 3.8 times, respectively).

CONCLUSIONS

Orange juice (750 mL/d) improved blood lipid profiles in hypercholesterolemic subjects, confirming recommendations to consume >/=5-10 servings of fruit and vegetables daily.

Physicians' attitudes about involvement in lethal injection for capital punishment

BACKGROUND

Physicians could play various roles in carrying out capital punishment via lethal injection. Medical societies like the American Medical Association (AMA) and American College of Physicians have established which roles are acceptable and which are disallowed. No one has explored physicians' attitudes toward their potential roles in this process.

METHODS

We surveyed physicians about how acceptable it was for physicians to engage in 8 actions disallowed by the AMA and 4 allowed actions involving lethal injection. Questions assessing attitudes toward capital punishment and assisted suicide were included. The impact of attitudinal and demographic variables on the number of disallowed actions deemed acceptable was analyzed via analysis of variance and multiple logistic regression analysis.

RESULTS

Four hundred eighty-two physicians (51%) returned questionnaires. Eighty percent indicated that at least 1 of the disallowed actions was acceptable, 53% indicated that 5 or more were acceptable, and 34% approved all 8 disallowed actions. The percentage of respondents approving of disallowed actions varied from 43% for injecting lethal drugs to 74% for determining when death occurred. All 4 allowed actions were deemed acceptable by the majority of respondents. Favoring the death penalty (P<.001) and the acceptance of assisted suicide (P<.001) were associated with an increased number of disallowed actions that were deemed acceptable.

CONCLUSIONS

Despite medical society policies, the majority of physicians surveyed approved of most disallowed actions involving capital punishment, indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes. It is possible that the lack of stigmatization by colleagues allows physicians to engage in such practices. Arch Intern Med. 2000;160:2912-2916

[An unusual case of the otogenic purulent thrombosis of the sigmoid sinus and internal jugular vein]

The authors present a case of 51 years old female suffering from the purulent thrombophlebitis of the sigmoid sinus and internal jugular vein. The disease developed in the course of chronic otitis media. During first 2 weeks she was treated with antibiotics because of the septic fever without significant otogenic symptoms. An incidental otolaryngologic examination showed the reason of the illness. The authors emphasise the thrombophlebitis process extended from transverse sinus to the lower end of internal jugular vein. Nowadays the otogenic thrombophlebitis complications are rare, but the knowledge of them is indispensable in the everyday practice. The authors emphasise the necessity of cooperation otolaryngologists with other specialists. Especially it is important in the Polish new model of health service, which place the main role of the treatment to general practitioners.

Interaction of carbon dioxide and sympathetic nervous system activity in the regulation of cerebral perfusion in humans

Recent studies suggest that activation of the sympathetic nervous system either directly or indirectly influences cerebrovascular tone in humans even within the autoregulatory range. In 6 healthy subjects (aged 29+/-4 years), we used transcranial Doppler sonography to determine cerebral blood flow velocity during sympathetic activation elicited through head-up tilt (HUT) and sympathetic deactivation through ganglionic blockade. PaCO(2) was manipulated through hyperventilation and CO(2) breathing (5%). With subjects in the supine position and during HUT, mean arterial pressure was not influenced by PaCO(2). During ganglionic blockade, mean arterial pressure decreased markedly with hyperventilation (-13+/-1.9 mm Hg). Manipulation of sympathetic tone elicited only mild changes in cerebral blood flow (64+/-5.8 cm/s supine, 58+/-4.9 cm/s upright, and 66+/-6.2 cm/s during ganglionic blockade; P:=0.07 by ANOVA). The slope of the regression between PaCO(2) and mean velocity was 1.6+/-0.18 cm/(s. mm Hg) supine, 1.3+/-0.14 cm/(s. mm Hg) during HUT, and 2.3+/-0.36 cm/(s. mm Hg) during ganglionic blockade (P:<0.05). Spontaneous PaCO(2) and ventilatory response to hypercapnia were also modulated by the level of sympathetic activity. Changes in sympathetic tone have a limited effect on cerebral blood flow at normal PaCO(2) levels. However, the sympathetic nervous system seems to attenuate the CO(2)-induced increase in cerebral blood flow. This phenomenon may indicate a moderate direct effect of the sympathetic nervous system on the cerebral vasculature. Furthermore, sympathetic activation tends to increase ventilation and thus can indirectly increase cerebrovascular tone.

The impact of patient-centered care on outcomes

BACKGROUND

We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization.

METHODS

We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients' health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables.

RESULTS

Patient-centered communication was correlated with the patients' perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals.

CONCLUSIONS

Patient-centered communication influences patients' health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

Human parvovirus B19: prevalence of viral DNA in volunteer blood donors and clinical outcomes of transfusion recipients

BACKGROUND AND OBJECTIVES

Blood donor units are not screened for human parvovirus B19 (B19) even though it can be acquired via blood products. We estimated the prevalence of B19 in a US volunteer blood donor population and determined the clinical outcomes of transfusion recipients.

MATERIALS AND METHODS

Donor units were screened for B19 DNA by PCR, and positive units analyzed by EIA for B19 Ig. Unit usage was determined and recipient chart review conducted.

RESULTS

B19 DNA was detected in 11/9, 568 allogeneic units (0.1%), of which 3 had no measurable B19 Ig. One individual developed anemia consistent with B19 infection after receiving a DNA+ unit lacking B19 Ig.

CONCLUSIONS

The apparent low incidence of disease in patients transfused with B19 DNA+ components may be due to coexistence of neutralizing antibodies in donors and/or recipients.

Efficacy of tissue plasminogen activator administration on patency of hemodialysis access catheters

Patients with end-stage renal disease use hemodialysis catheters for either temporary or permanent blood access. Recurrent thrombosis and fibrin sheath formation are common causes of poor or inadequate blood flow rates that require intervention. We studied the effect of tissue plasminogen activator (tPA) in reestablishing adequate blood flow rates through nonfunctional vascular catheters in 22 consecutive chronic hemodialysis patients. From January 1, 1999, to May 20, 1999, there were 56 instances in which tPA was used in an attempt to improve blood flow rates. In all instances, 2 mg of tPA was infused into each port of a dual-lumen internal jugular catheter. Dwell time ranged between 2 and 96 hours (median, 24 hours), and patient follow-up ranged between 47 and 140 days (median, 133.5 days). tPA was effective in establishing adequate blood flow rates (>/=200 mL/min) during the next dialysis session in 49 of 56 cases (87.5%). Seven additional interventions were required because of early or late tPA failure (one fibrin sheath stripping, one catheter replacement for kinking, one catheter replacement for central venous stenosis, and four catheter replacements for persistently poor blood flow rates), and eight catheters were replaced for infection. Thus, further interventions to achieve adequate blood flow rates were required in 12.5% of the cases because of early or late tPA failure. tPA appears to be as effective as urokinase for reestablishing adequate blood flow rates through hemodialysis catheters that are thrombosed or have low blood flow rates.

Multiple selectin blockade with a small molecule inhibitor downregulates liver chemokine expression and neutrophil infiltration after hemorrhagic shock

BACKGROUND

The purpose of this study was to investigate the regulatory effect of a small molecule selectin inhibitor in the liver by examining the functional, structural, and survival response of animals subjected to hemorrhagic shock and to determine the liver infiltration of neutrophils and the regulation of chemokine expression. Selectins play an important role in the development of the lesions associated with ischemia/reperfusion and hemorrhagic shock. Blocking individually the selectin family of adhesion molecules with monoclonal antibodies has resulted in better organ function and survival. To our knowledge, there are no studies demonstrating the beneficial effect of multiple selectin blockade with a small molecule inhibitor under conditions of hemorrhagic shock.

METHODS

Forty-eight Sprague-Dawley rats were subjected to hemorrhagic shock. Three groups of animals were included (n = 16/group), i.e., the sham, control, and treated groups, which received a small molecule selectin inhibitor (TBC-1269) at 25 mg/kg body weight after the bleeding began. The following parameters were evaluated: fluid requirements during resuscitation, liver injury tests (aspartate aminotransferase, alanine aminotransferase), liver histology and myeloperoxidase, and macrophage inflammatory protein-2 mRNA and cytokine-induced neutrophil chemoattractant mRNA in liver tissue, and animal survival at 3 days. Statistical analysis included Student's t test and analysis of variance when indicated.

RESULTS

Significant improvement in liver function and histology was noted in the treated group. Survival was also improved, although it is not known whether liver failure was the most proximate cause of lethality. Infiltration of neutrophils, measured by tissue myeloperoxidase, was significantly decreased in livers of treated animals. No significant changes were noted in fluid requirements. The small molecule selectin inhibitor group showed a down-regulating effect on liver macrophage inflammatory protein-2 and cytokine-induced neutrophil chemoattractant mRNA expression associated with less accumulation of neutrophils in the liver.

CONCLUSION

This study supports the role that selectins play in the pathogenesis of hemorrhagic shock. The mechanism of protection seen after multiple selectin blockade (TBC-1269) centered, in part, around the infiltration of liver neutrophils, probably dependent on the induction of macrophage inflammatory protein-2 and cytokine-induced neutrophil chemoattractant mRNA expression in liver tissue.

Sympathetically mediated hypertension in autonomic failure

BACKGROUND

Approximately 50% of patients with primary autonomic failure have supine hypertension. We investigated whether this supine hypertension could be driven by residual sympathetic activity.

METHODS AND RESULTS

In patients with multiple system atrophy (MSA) or pure autonomic failure (PAF), we studied the effect of oral yohimbine on seated systolic blood pressure (SBP), the effect of ganglionic blockade (with trimethaphan) on supine SBP and plasma catecholamine levels, and the effect of alpha(1)-adrenoreceptor blockade (phentolamine) on supine SBP. The SBP response to yohimbine was greater in patients with MSA than in those with PAF (area under the curve, 2248+/-543 versus 467+/-209 mm Hg. min; P=0.022). MSA patients with a higher supine SBP had a greater response than those with a lower supine SBP (3874+/-809 versus 785+/-189 mm Hg. min; P=0. 0017); this relationship was not seen in PAF patients. MSA patients had a marked depressor response to low infusion rates of trimethaphan; the response in PAF patients was more variable. Plasma norepinephrine decreased in both groups, but heart rate did not change in either group. At 1 mg/min, trimethaphan decreased supine SBP by 67+/-8 and 12+/-6 mm Hg in MSA and PAF patients, respectively (P<0.0001). Cardiac index and total peripheral resistance decreased in MSA patients by 33.4+/-5.8% and 40.7+/-9.5%, respectively (P=0. 0015). Patients having a depressor response to trimethaphan also had a depressor response to phentolamine. In MSA patients, the pressor response to yohimbine and the decrease in SBP with 1 mg/min trimethaphan were correlated (r=0.98; P=0.001).

CONCLUSIONS

Residual sympathetic activity drives supine hypertension in MSA. It contributes to, but does not completely explain, supine hypertension in PAF.

Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis

BACKGROUND

Microlithiasis has been implicated in the etiology of idiopathic pancreatitis and biliary-type pain in patients with intact gallbladders. Contrast injection at endoscopic retrograde cholangiopancreatography (ERCP) is used to confirm access into the bile duct and bile is also aspirated to look for microlithiasis. It is not known whether contrast agents contain crystals that could mimic true microlithiasis.

METHODS

Four mL of 2 contrast agents (Hypaque and Omnipaque) were examined after centrifugation under polarizing microscopy. In the second part of the study, bile aspirated during ERCP with contrast injection was examined for microlithiasis and contrast pseudomicrolithiasis.

RESULTS

Contrast agents exhibited pseudomicrolithiasis that mimicked calcium bilirubinate granules. Pathologists participating in the study were not aware of contrast pseudomicrolithiasis. Nine of twelve (75%) patients would have been reported as having microlithiasis and would possibly have undergone an unnecessary cholecystectomy.

CONCLUSION

When bile collected during ERCP is to be examined for microlithiasis, it should be collected without contamination by a contrast agent. If this is not possible, pathologists should be aware that contrast can cause pseudomicrolithiasis.

Orthostatic intolerance: a disorder of young women

Orthostatic intolerance (OI) is a cause of significant disability in otherwise healthy women seen by gynecologists. Orthostatic tachycardia is often the most obvious hemodynamic abnormality found in OI patients, but symptoms may include dizziness, visual changes, discomfort in the head or neck, poor concentration, fatigue, palpitations, tremulousness, anxiety, and, in some cases, fainting (syncope). It is the most common disorder of blood pressure regulation after essential hypertension, and patients with OI are traditionally women of childbearing age. Estimates suggest that at least 500,000 Americans suffer from some form of OI, and such patients comprise the largest group referred to centers specialized in autonomic disorders. This article reviews recent advances made in the understanding of this condition, potential pathophysiological mechanisms contributing to orthostatic intolerance, and therapeutic alternatives currently available for the management of these patients.

Interpersonal psychotherapy for anorexia nervosa

OBJECTIVE

This paper outlines the rationale for treating individuals with anorexia nervosa using interpersonal psychotherapy.

METHOD

We review theoretical, empirical, and psychotherapy literature relating to interpersonal functioning in anorexia nervosa.

RESULTS

Etiological theories emphasize interpersonal and family dysfunction in the development of anorexia nervosa. Research supports the notion that families of individuals with anorexia nervosa have dysfunctional patterns of communication. The history of treatment for anorexia nervosa emphasizes the need for resolution of interpersonal dysfunction, within the traditions of psychodynamic, family therapy, and multidimensional therapies.

DISCUSSION

Interpersonal psychotherapy is a time-limited psychotherapy based on the notion that regardless of etiology, interpersonal relationships are intertwined with symptomatology. The goals of the therapy are to improve interpersonal functioning and thereby decrease symptomatology. Factors identified as important in the development of anorexia nervosa are readily conceptualized within the interpersonal psychotherapy problem areas of grief, interpersonal disputes, interpersonal deficits, and role transitions.

Orthostatic intolerance and tachycardia associated with norepinephrine-transporter deficiency

BACKGROUND

Orthostatic intolerance is a syndrome characterized by lightheadedness, fatigue, altered mentation, and syncope and associated with postural tachycardia and plasma norepinephrine concentrations that are disproportionately high in relation to sympathetic outflow. We tested the hypothesis that impaired functioning of the norepinephrine transporter contributes to the pathophysiologic mechanism of orthostatic intolerance.

METHODS

In a patient with orthostatic intolerance and her relatives, we measured postural blood pressure, heart rate, plasma catecholamines, and systemic norepinephrine spillover and clearance, and we sequenced the norepinephrine-transporter gene and evaluated its function.

RESULTS

The patient had a high mean plasma norepinephrine concentration while standing, as compared with the mean (+/-SD) concentration in normal subjects (923 vs. 439+/-129 pg per milliliter [5.46 vs. 2.59+/-0.76 nmol per liter]), reduced systemic norepinephrine clearance (1.56 vs. 2.42+/-0.71 liters per minute), impairment in the increase in the plasma norepinephrine concentration after the administration of tyramine (12 vs. 56+/-63 pg per milliliter [0.07 vs. 0.33+/-0.37 pmol per liter]), and a disproportionate increase in the concentration of plasma norepinephrine relative to that of dihydroxyphenylglycol. Analysis of the norepinephrine-transporter gene revealed that the proband was heterozygous for a mutation in exon 9 (encoding a change from guanine to cytosine at position 237) that resulted in more than a 98 percent loss of function as compared with that of the wild-type gene. Impairment of synaptic norepinephrine clearance may result in a syndrome characterized by excessive sympathetic activation in response to physiologic stimuli. The mutant allele in the proband's family segregated with the postural heart rate and abnormal plasma catecholamine homeostasis.

CONCLUSIONS

Genetic or acquired deficits in norepinephrine inactivation may underlie hyperadrenergic states that lead to orthostatic intolerance.

The pressor response to water drinking in humans : a sympathetic reflex?

BACKGROUND

Water drinking increases blood pressure profoundly in patients with autonomic failure and substantially in older control subjects. The mechanism that mediates this response is not known.

METHODS AND RESULTS

We studied the effect of drinking tap water on seated blood pressure in 47 patients with severe autonomic failure (28 multiple system atrophy [MSA], 19 pure autonomic failure patients [PAF]). Eleven older controls and 8 young controls served as control group. We also studied the mechanisms that could increase blood pressure with water drinking. Systolic blood pressure increased profoundly with water drinking, reaching a maximum of 33+/-5 mm Hg in MSA and 37+/-7 in PAF mm Hg after 30 to 35 minutes. The pressor response was greater in patients with more retained sympathetic function and was almost completely abolished by trimethaphan infusion. Systolic blood pressure increased by 11+/-2.4 mm Hg in elderly but not in young controls. Plasma norepinephrine increased in both groups. Plasma renin activity, vasopressin, and blood volume did not change in any group.

CONCLUSIONS

Water drinking significantly and rapidly raises sympathetic activity. Indeed, it raises plasma norepinephrine as much as such classic sympathetic stimuli as caffeine and nicotine. This effect profoundly increases blood pressure in autonomic failure patients, and this effect can be exploited to improve symptoms due to orthostatic hypotension. Water drinking also acutely raises blood pressure in older normal subjects. The pressor effect of oral water is an important yet unrecognized confounding factor in clinical studies of pressor agents and antihypertensive medications.

Prevalence of herpes simplex virus in malignant laryngeal lesions

OBJECTIVE

To determine the prevalence of herpes simplex virus (HSV) in malignant laryngeal lesions.

STUDY DESIGN

Retrospective review.

MATERIALS AND METHODS

Paraffin-embedded, histologically confirmed specimens containing benign laryngeal lesions, squamous cell carcinoma of the larynx, and squamous cell carcinoma of the oral cavity were identified from archived surgical specimens. Biopsies of normal-appearing oral cavity tissue were also obtained from fresh-frozen cadavers. These tissues were analyzed for the presence of HSV DNA using polymerase chain reaction techniques. Patient charts were reviewed for patient demographics, risk factors, stage, clinical course, treatment, and outcome.

RESULTS

HSV was detected in nine laryngeal squamous cell carcinomas (75%) and in none of the benign laryngeal lesions (P = .0001). HSV was also found in three oral cavity squamous cell carcinomas (25%) and in none of the controls (P = .049).

CONCLUSION

HSV is more prevalent in squamous cell carcinoma of the larynx and oral cavity than in their respective control groups, suggesting a role for carcinogenesis. HSV is more prevalent in squamous cell carcinoma of the larynx than of the oral cavity. Further studies to determine the role of HSV as a cocarcinogen and its interrelationship with other environmental factors in laryngeal cancer are warranted.

Innovations in section 1115 demonstrations

This article discusses how States have taken advantage of the flexibility afforded under section 1115 research and demonstration authority. It describes how States have used Section 1115 authority to develop innovations in outreach and enrollment, eligibility requirements, access, benefits, quality assurance, payment, safety net providers, and special needs populations. It concludes by discussing the future challenges that all the players in Medicaid demonstration projects are facing.