Adult onset Still's disease: clinical experience with 18 patients over 15 years in northern India

Over a 15 year period 18 patients (eight men, 10 women), 16-50 years old, were diagnosed as having adult onset Still's disease. Fever and arthralgia were always present but prominent lymphadenopathy was uncommon and the serosa were rarely affected. The typical rash of this disease was observed in nine patients. Several complications, including deforming arthritis, amyloidosis, granulomatous hepatitis, uveitis, scleritis, cutaneous vasculitis, and cardiomyopathy, were observed during follow up. Two patients were affected by a nosocomial infection during immunosuppressive treatment for uncontrolled disease. There were no characteristic features at necropsy. Ten patients had a monocyclic course that responded well to aspirin and indomethacin, whereas eight had a polycyclic pattern which invariably required treatment with corticosteroids. Serious complications developed exclusively in the latter group. This group of patients requires early, intensive disease modifying treatment.

Metastatic parathyroid carcinoma: a radiological, biochemical and symptomatic response to metastectomy

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The efficacy of an albendazole intraruminal controlled-release device against gastrointestinal parasitism in lambs

The effectiveness of albendazole in a controlled-release bolus in controlling gastrointestinal nematodes in lambs was assessed during the summer of 1986. Faecal egg counts were almost entirely negative throughout in the treated group and larval challenge remained low at below 2000 larvae kg-1. Untreated control lambs showed a characteristic pattern of auto-infection, culminating in a peak pasture larval count of over 70,000 larvae kg-1 and an outbreak of parasitic gastroenteritis in September associated with a serum pepsinogen concentration of 1.183 IU tyrosine and a mean worm burden of 91,165 nematodes at necropsy, including Ostertagia, Trichostrongylus and Nematodirus species. Subject to the restrictions imposed by the size of the bolus, this was considered to be a highly effective method of seasonal parasite control.

Clinical profile in Barrett's esophagus: who should be screened for cancer?

A retrospective survey identified 96 patients (58 males) with Barrett's esophagus, diagnosed at the Royal Melbourne Hospital between 1978 and 1986. The age at presentation varied from 20 to 93 years, and 43% were greater than 70 years. Heartburn was a presenting symptom in 71%, regurgitation into the pharynx in 54%, dysphagia in 31% and hematemesis or melena in 29%. At endoscopy, the length of Barrett's epithelium ranged from 3 cm to 15 cm. Macroscopic esophagitis was observed in 69%, benign esophageal strictures in 14% and a co-existent adenocarcinoma of the lower esophagus in 10% of patients. Only 30% of the patients were cigarette smokers at the time of diagnosis, but 64% drank alcohol (9% greater than 80 g alcohol daily). Patients with esophageal cancer at presentation were more likely to be male and cigarette smokers (Fisher's exact probability test). It has been suggested that patients with Barrett's esophagus should be screened to detect the early development of esophageal cancer. If patients who already have cancer, the elderly (age greater than 70 years) and those with a chronic alcohol problem (greater than 80 g intake daily) are excluded from endoscopic cancer surveillance, only 42% of the patients described in this survey would be eligible for enrollment in such a program. This represents a recruitment of only 5 new patients yearly in a large teaching hospital endoscopy unit.

Anti-tick saliva antibody: a biologic marker of tick exposure that is a risk factor for Lyme disease seropositivity

Anti-tick saliva antibody (ATSA) has potential as a biologic marker of exposure to tick bites. In 1989, we conducted a cross-sectional study of 304 outdoor workers in Monmouth County, New Jersey, to evaluate associations between self-reported tick exposure, ATSA status, and Lyme disease antibody status. ATSA levels 1) were correlated with an index of tick exposure on the basis of three self-reported measures of tick exposure and outdoor hours worked per week (p = 0.01); 2) were consistently higher in pet owners compared with persons without pets (p = 0.03); and 3) when examined by duration since last tick bite, peaked at 3-5 weeks after tick bite and then declined (p = 0.06). ATSA levels dichotomized at the 75th percentile (approximately two standard deviations above the mean ATSA optical density of 25 subjects who denied recent tick exposure) were associated with self-reported tick exposure: adjusted odds ratios for high ATSA levels were 4.2 (95% confidence interval (CI) 0.9-18.9) for moderate (versus none) tick exposure and 5.8 (95% CI 1.2-27.2) for high (versus none) tick exposure. Finally, high ATSA levels were associated with Lyme disease seropositivity, with an adjusted odds ratio of 3.2 (95% CI 1.3-7.6). The data suggest that ATSA is a biologic marker of tick exposure that is a risk factor for Lyme disease seropositivity.

Extreme ultraviolet performance of a multilayer coated high density toroidal grating

The performance of a multilayer coated diffraction grating has been evaluated at EUV wavelengths both in terms of absolute efficiency and spectral resolution. The application of a ten-layer Ir/Si multilayer coating to a 3600-lines/mm blazed toroidal replica grating produced a factor of 9 enhancement in peak efficiency near the design wavelength approximately 30 nm in first order, without degrading its excellent quasistigmatic spectral resolution. The measured EUV efficiency peaked at 3.3% and was improved over the full spectral range between 25 and 35 nm compared with the premultilayer replica which had a standard gold coating. In addition, the grating's spectral resolution of >5000 was maintained.

Olfactory sensations produced by high-energy photon irradiation of the olfactory receptor mucosa in humans

During irradiation of volumes that incorporate the olfactory system, a proportion of patients have complained of a pungent smell. A retrospective study was carried out to determine the prevalence of this side-effect. A questionnaire was sent to 40 patients whose treatment volumes included the olfactory region and also to a control group treated away from this region. The irradiated tumor volumes included the frontal lobe, whole brain, nasopharynx, pituitary fossa, and maxillary antrum. Of the 25 patients who replied, 60% experienced odorous symptoms during irradiation. They described the odor as unpleasant and consistent with ozone. Stimulation of olfactory receptors is considered to be caused by the radiochemical formation of ozone and free radicals in the mucus overlying the olfactory mucosa.

Detection of Clostridium botulinum types C and D toxin by ELISA

An ELISA to detect Clostridium botulinum type D toxin was developed using polyclonal antibodies to a semi-purified toxic complex of the neurotoxin. Sensitivity of the ELISA for detecting type C and type D toxin compared with mouse inoculation was 70% and specificity 96% on samples from animals with botulism diagnosed on clinical signs and herd history. However, both mouse inoculation and the ELISA failed to detect toxin in many animals with a presumptive diagnosis of botulism. Some cross-reaction was seen with Clostridium novyi type A, but not with other clostridial species. While the ELISA described here cannot replace mouse inoculation for the diagnosis of botulism, it is a useful additional test.

Performance of multilayer coated diffraction gratings in the EUV

Performance of multilayer coated diffraction gratings has been evaluated in the extreme UV. The application of multilayer coatings to two blazed gratings has produced a significant enhancement in grating efficiency in the 300-A spectral region in first order.

Sudden Death During Basketball Games

In brief Four athletes, aged 16 to 20, died shortly after they collapsed while playing basketball. Preparticipation screening had revealed no cardiac abnormality in three of them. The fourth, who had been advised not to participate in sports, had been treated for hyperlipidemia at age 7 and for exercise-related syncope at age 15. Physicians should make a concerted effort to identify those athletes with risk factors (eg, exertional syncope, chest pain, or dyspnea) through careful history taking and physical examination.

Appetite, digestive efficiency, feed utilization and carcass evaluation of housed calves naturally infected with gastrointestinal nematodes

The progress of two groups of 10 calves, which had previously been exposed to trichostrongyle infections by grazing infected pastures, was monitored from housing in October to slaughter the following April. Each of the animals of one group had received a morantel sustained release bolus, the other control group remained untreated. The high faecal egg counts and serum pepsinogen concentrations, together with the clinical signs of ostertagiosis observed in the controls in October, persisted during the first month of housing but improved thereafter. From late November onwards, no difference in feed intake and digestive efficiency was observed between the groups. The control calves exhibited a significantly greater feed conversion efficiency over the period February-April, (7.5 vs. 12.3 kg feed kg-1 liveweight gain, P less than 0.001). This reduced the liveweight advantage of the MSRB group over the controls at housing to 25 kg.

Elevated serum IgE, eosinophilia, and lung function in rubber workers

We previously reported an outbreak of acute respiratory illness associated with eosinophilia in a group of rubber workers who performed a thermoinjection process in which synthetic rubber was heated and then injected onto metal molds. This study was conducted to determine if persistent respiratory health effects were associated with this work area and to explore the possible allergic etiology of this syndrome. A survey was performed 1 mo after a major improvement in area ventilation and consisted of baseline, cross-shift, and cross-week spirometry; diffusing capacity; serum immunoglobulin E (IgE), total eosinophil count; and skin patch testing. Baseline lung function, cross-shift, and cross-week spirometry were not significantly worse in the exposed group as compared to the control group. However, either eosinophilia (greater than 450/mm3) or elevated serum IgE (greater than 470 ng/ml) were present in 44% of exposed workers vs. 11% of the control group (p = .003). Nine months later, neither eosinophilia nor elevated IgE were associated with employment in this work area. We conclude that employment in the thermoinjection process was associated with eosinophilia and elevated IgE, which suggests sensitization to one of the components of the rubber, although no effect on pulmonary function could be demonstrated.

A new gastric carcinoma cell line (LIM1839) derived from a young Caucasian male

We describe a new and unique gastric carcinoma cell line (LIM1839) derived from a young Caucasian male with rapidly progressing disease. The cell line grows with a pleomorphic morphology and has been in continuous culture for more than 3 years. The cells cannot be cloned in semi-solid agar or grown in nude mice despite numerous attempts. The karyotype of the cultured cells is highly abnormal with a large number of structural and numerical changes. Some chromosomes are dicentric and this feature has persisted in this culture. The cells express one of the small-intestinal dipeptidases, aminopeptidase N, but do not express dipeptidyl peptidase IV or the disaccharidases, sucrase isomaltase or maltase glucoamylase. The cells express high levels of EGF receptors and of messenger RNA for insulin-like growth factor II.

High-dose chemotherapy with busulphan and cyclophosphamide and bone-marrow transplantation for drug-sensitive malignancies in adults: a preliminary report

The technique of high-dose chemotherapy and bone-marrow transplantation takes advantage of any potential dose-response effect in the treatment of cancer and the ability of infused marrow to circumvent severe myelotoxicity. We report our initial experience of 20 high-dose chemotherapy procedures with busulphan and cyclophosphamide as the treatment regimen. Autologous (14 patients), human leukocyte antigen-matched, sibling-allogeneic (five patients) and identical-twin (one patient) transplantations were performed in patients with leukaemias (12 patients), lymphomas (seven patients) or a germ-cell tumour (one patient). One in-hospital and one late death occurred as a result of the toxicity of high-dose chemotherapy. All evaluable patients demonstrated bone-marrow engraftment and became independent of blood transfusions. Five of six patients who were treated in partial remission or relapse obtained a complete remission. Seven patients have relapsed. Eleven patients currently are alive and disease-free and nine patients have returned to their full-time occupations. High-dose chemotherapy can be undertaken with an over-all morbidity that is similar to that which is experienced during the induction chemotherapy of acute leukaemia.

An outbreak of ehrlichiosis in members of an Army Reserve unit exposed to ticks

An outbreak of unexplained illness occurred in members of an army reserve unit after field training in an area of New Jersey endemic for Lyme disease. Nine (12%) of the 74 who attended the exercise had serological evidence of Ehrlichia infection, defined as a single rise in titer of antibody to Ehrlichia canis greater than or equal to 1:160 four weeks after training. Two reservists with early serum samples had documented seroconversion, defined by a four-fold or greater increase in titer of antibody to E. canis, with a peak titer of greater than or equal to 1:160. Reservists with serological evidence of Ehrlichia infection were more than three times as likely to report arthralgia, myalgia, headache, appetite loss, nausea, eye pain, and abdominal pain than the other reservists. No reservist with serological evidence of Ehrlichia infection was hospitalized and most had minimal or no symptoms. This outbreak of ehrlichiosis suggests that the usual symptoms of Ehrlichia infection are milder than previously reported and that ehrlichiosis must be considered in symptomatic persons with recent tick exposure.

Urinary tract endometriosis

Although endometriosis is a common gynecologic pathologic phenomenon, involvement of the urinary tract is relatively rare. The clinical presentation and course of urinary system disease is extremely variable, as illustrated by the seven cases presented in this report. Therapy primarily is surgical, but a thorough understanding of the disease process and a complete knowledge of the patient's history and desires for fertility conservation are necessary to plot the most appropriate treatment course. Bladder involvement is more common, and usually less devastating, than either ureteral or kidney involvement. No signs, symptoms, or physical findings are pathognomonic, and the clinician must maintain a high index of suspicion in all cases of advanced pelvic endometriosis.

A prospective randomized trial of ofloxacin vs. doxycycline in the treatment of uncomplicated male urethritis

One hundred fourteen men with uncomplicated urethritis were randomized to receive 1 week of therapy with either doxycycline (100 mg twice daily) or ofloxacin (300 mg twice daily). Of the 109 men completing the post-treatment visit, 56 received ofloxacin and 52 (93%) were clinically cured. Forty four (83%) of the 53 men treated with doxycycline were cured. All 30 patients with gonorrhea (including three with penicillinase-producing Neisseria gonorrhoeae [PPNG] isolates) who were treated with ofloxacin became culture-negative, as compared with 32 of 34 patients receiving doxycycline. In contrast, three of 18 patients with Chlamydia trachomatis were microbiologic failures after ofloxacin therapy, while all ten treated with doxycycline were cured. Adverse effects of both treatment regimens were generally mild, and compliance was excellent except for one patient receiving doxycycline. These results show that ofloxacin, in a dosage of 300 mg taken orally twice daily for seven days, is an effective treatment for uncomplicated urethritis in men but may not reliably cure chlamydial infections.

Control of gastrointestinal parasitism with an oxfendazole pulse-release anthelmintic device

The efficacy of a pulse-release oxfendazole bolus (OPRB) against gastrointestinal nematodes was evaluated under field conditions and compared with a sustained release morantel bolus (MSRB). Three groups of 10 calves were grazed from May to September on adjacent, similarly contaminated 3-acre paddocks. One group was dosed at turnout with the OPRB, the second group with the MSRB and the third group left as nontreated controls. Pasture larval counts peaked at greater than 60,000 larvae/kg dry weight of herbage in September on the control paddock, associated with a mean egg count of 1040 eggs/g faeces and clinical symptoms. A low rise in larval counts occurred on the MSRB plot, and also low helminth egg counts. On the OPRB plot, pasture larvae and faecal egg counts were recorded only intermittently; the September egg counts were only 3.5% of those of the controls; serum pepsinogen data showed a similar picture. At the end of the experiment, the OPRB calves had a mean weight advantage of 40 kg over the controls, and 12 kg over the MSRB group. Feed intakes were highest in the OPRB group in July and September.

Catheter sepsis during parenteral nutrition: the safety of long-term OpSite dressings

A prospective controlled study of the safety of various catheter dressing protocols was carried out in 168 patients receiving parenteral nutrition via an infraclavicular central venous catheter. Four protocols were compared: 36 patients received gauze dressings changed three times per week; 31 received OpSite dressings changed every 7th day (OpS-7), 32 received OpSite changed every 10th day (OpS-10), and 69 received OpSite changed twice weekly (OpS-ICU). Mean duration of parenteral nutrition was approximately 2 weeks and all groups were well matched except that OpS-ICU patients suffered more frequently from an acute illness. Catheter-related sepsis was identified by clinical signs of systemic sepsis, positive peripheral venous blood and catheter-tip cultures and/or defervescence of fever after catheter removal. Catheter-related sepsis rates were low in all groups: 1/36 for Gauze, 0/31 for OpS-7, 1/32 for OpS-10, and 2/69 for OpS-ICU. Septicemia attributable to causes apart from catheter sepsis occurred in two, two, three, and four patients, respectively. Bacterial colonization of skin beneath OpSite was no more common in the OpS-10 than in the other groups. Signs of inflammation at catheter insertion sites were common in all groups but did not relate closely to skin colonization. OpSite can be safely applied to central venous catheters inserted under strict aseptic conditions, even in patients with open septic drainage. Dressings can be left in place for 7 days with a margin of safety lasting to 10 days, thus saving on cost of materials and nursing time.

Current management of severe exercise-related cardiac events

Severe cardiac events during either exercise testing or cardiac rehabilitation are described in five patients. The three events related to exercise testing involved patients with atypical chest pain which, in retrospect, probably reflected unstable angina pectoris or coronary vasospasm (or both). Prompt coronary angiography with subsequent percutaneous transluminal coronary angioplasty was performed. Two cardiac arrests (one fatal) occurred during participation in cardiac rehabilitation programs. One was caused by primary ventricular fibrillation. Electrophysiologic testing was used in determining the efficacy of the drug. The fatality was due to an acute myocardial infarction. On-site intravenous thrombolytic therapy might prove useful in similar events in the future. Comparisons of surveys published in the 1970s with those in the 1980s show that the mortality and morbidity during exercise testing remain low and that similar rates during cardiac rehabilitation are even lower; however, these cases exemplify that emergency situations can and do arise, necessitating prompt intervention and aggressive subsequent management.