Body representation among adults with phantom limb pain: Results from a foot identification task

BACKGROUND

Impaired body representation (i.e. disrupted body awareness or perception) may be a critical, but understudied, factor underlying phantom limb pain (PLP). This cross-sectional study investigated whether adults with lower-limb loss (LLL) and PLP demonstrate impaired body representation as compared to Pain-Free peers with and without LLL.

METHODS

Participants (n = 41 adults with PLP, n = 27 Pain-Free peers with LLL, n = 39 Controls with intact limbs) completed an online foot identification task. Participants judged whether randomized images depicted left or right feet (i.e. left-right discrimination) as quickly as possible without limb movement. Using two Generalized Estimating Equations, effects of group, image characteristics (i.e. side, foot type, view, angle) and trial block (i.e. 1-4) were evaluated, with task response time and accuracy as dependent variables (a ≤ 0.050).

RESULTS

Adults with PLP demonstrated slower and less accurate performance as compared to Controls with intact limbs (p = 0.018) but performed similarly to Pain-Free peers with LLL (p = 0.394). Significant three-way interactions of group, view and angle indicated between-group differences were greatest for dorsal-view images, but smaller and angle-dependent for plantar-view images. While all groups demonstrated significant response time improvements across blocks, improvements were greatest among adults with PLP, who also reported significant reductions in pain intensity.

CONCLUSIONS

Adults with PLP demonstrate body representation impairments as compared to Controls with intact limbs. Body representation impairments, however, may not be unique to PLP, given similar performance between adults with and without PLP following LLL.

SIGNIFICANCE

Following lower-limb loss, adults with phantom limb pain (PLP) demonstrate impaired body representation as compared to Controls with intact limbs, evidenced by slower response times and reduced accuracy when completing a task requiring mental rotation. Importantly, 80% of participants with pre-task PLP reported reduced pain intensity during the task, providing compelling evidence for future investigations into whether imagery-based, mind-body interventions have positive effects on PLP.

The diagnostic accuracy of the faecal immunochemical test for colorectal cancer in risk-stratified symptomatic patients

INTRODUCTION

The faecal immunochemical test detects blood in the faeces, reporting faecal haemoglobin quantitatively in micrograms of haemoglobin per gram of faeces. The aim of this pilot study was to determine the feasibility of using the faecal immunochemical test as a rule-out test in symptomatic patients at low and high risk of colorectal cancer.

MATERIAL AND METHODS

Between November 2016 and October 2017, consecutive symptomatic patients within a multicultural part of London were recruited to perform a faecal immunochemical test prior to colonoscopy. Analysis was performed on the HM-JACKarc analyser.

RESULTS

Faecal immunochemical test samples were returned by 298 patients who underwent colonoscopy. There was no significant variation in faecal haemoglobin levels by age, sex, ethnicity or deprivation. The overall detection rate for colorectal cancer was 100% at 2 µg/g and 92% at 10 µg/g. If a faecal haemoglobin threshold for investigation of 2 µg/g (ie detectable) or 10 µg/g had been employed, the number of colonoscopies would have been reduced by 70% and 84%, respectively, in all symptomatic patients. For low-risk patients, the sensitivity of the faecal immunochemical test for colorectal cancer at both thresholds of 2 µg/g or 10 µg/g remained 100%, with the number of colonoscopies reduced by 80% and 91%, respectively.

CONCLUSION

This study shows that the faecal immunochemical test is a promising technology that detected colorectal cancer in all high- or low-risk symptomatic patients in our cohort at a threshold of detectable faecal haemoglobin. Data from adequately powered cohort studies will elucidate the true diagnostic accuracy of the test and the rate and patterns of undetected colorectal cancer.

Outcomes of inflammatory bowel disease surgery in obese versus non-obese patients: a meta-analysis

BACKGROUND

Obesity is considered a risk factor for many chronic diseases and obese patients are often considered higher risk surgical candidates. The aim of this meta-analysis was to evaluate the outcomes of obese (body mass index ≥ 30 kg/m²) versus non-obese patients undergoing surgery for inflammatory bowel disease (IBD).

METHODS

PubMed, Scopus, and Embase libraries were searched up to March 2019 for studies comparing outcomes of obese with non-obese patients undergoing surgery for IBD. A meta-analysis was conducted using Review Manager software to create forest plots and calculate odds ratios and mean differences.

RESULTS

Four thousand three hundred and eleven patients from five observational studies were included. Obese patients were older at the time of surgery and more likely to have diabetes. Obese patients had longer operative times (MD 23.28, 95% CI 14.63-31.93, p < 0.001), higher intra-operative blood loss (MD 45.32, 95% CI 5.89-84.76, p = 0.02), longer length of stay (MD 0.90, 95% CI 0.60-1.20, p < 0.001), higher wound infection rates (OR 1.76, 95% CI 1.39-2.23, p < 0.001), and higher total postoperative complication rates (OR 1.33, 95% CI 1.04-1.70, p = 0.02).

CONCLUSIONS

Obesity is associated with significantly worse outcomes following IBD-specific surgery, including longer operative times, greater blood loss, longer length of stay, higher wound infection rates, and higher total postoperative complication rates. Clinicians should be mindful of these increased risks when counselling patients and consider weight reduction strategies where possible.

Association of pretreatment neutrophil-lymphocyte ratio and outcome in emergency colorectal cancer care

Introduction The association between the neutrophil-lymphocyte ratio (NLR) and outcome in elective colorectal cancer surgery is well established; the relationship between NLR and the emergency colorectal cancer patient is, as yet, unexplored. This paper evaluates the predictive quality of the NLR for outcome in the emergency colorectal cancer patient. Materials and Methods A total of 187 consecutive patients who underwent emergency surgery for colorectal cancer were included in the study. NLR was calculated from the haematological tests done on admission. Receiver operating characteristic analyses were used to determine the most suitable cut-off for NLR. Outcomes were assessed by mortality at 30 and 90 days using stepwise Cox proportional hazards regression. Results An NLR cut-off of 5 was found to have the highest sensitivity and specificity. At 30 days, age and time from admission to surgery were associated with increased mortality; a high NLR was associated with an increased risk of mortality in univariate but not multivariate analysis. At 90 days, age, NLR, time from admission to surgery and nodal status were all significantly associated with increased mortality on multivariate analysis. Conclusions Pre-operative NLR is a cheap, easily performed and useful clinical tool to aid prediction of outcome in the emergency colorectal cancer patient.

A comparison of the efficacy of darifenacin alone vs. darifenacin plus a Behavioural Modification Programme upon the symptoms of overactive bladder

PURPOSE

This study assessed the benefit of adding behavioural modification to darifenacin treatment for overactive bladder (OAB).

MATERIALS AND METHODS

The ABLE trial was a randomised, open-label, parallel-group, multicentre study of 12 weeks of darifenacin treatment [with voluntary up-titration from 7.5 mg once daily (qd) to 15 mg qd at week 2] alone or in combination with a Behavioural Modification Programme (BMP) for men and women with dry or wet OAB. Efficacy was assessed as the change in the number (per day) of micturitions (primary variable), urge urinary incontinence (UUI) episodes, urgency episodes, pads used and nocturnal voids. Health-related quality of life (HRQoL) was also evaluated. Tolerability and safety assessments included adverse events and the number of discontinuations.

RESULTS

Of 592 patients screened, 395 were randomised, 190 to darifenacin alone and 205 to darifenacin + BMP. At baseline, the majority of subjects were dry (mean 2.8 and three UUI episodes per day in the darifenacin and darifenacin + BMP groups respectively). At study end, darifenacin alone and darifenacin + BMP both produced significant reductions from baseline in median numbers of micturitions, UUI episodes, urgency episodes and nocturnal voids (all p < 0.05), but not in the number of pads used. HRQoL also improved. There were no significant differences between treatment groups in efficacy or HRQoL variables.

CONCLUSIONS

Darifenacin treatment provides a degree of normalisation of micturition variables and improvement in HRQoL that cannot be further enhanced by behavioural therapy of the type used in this study. Whether behavioural modification would add benefit over darifenacin treatment in patients with more pronounced incontinence problems remains to be determined.

Activation of peripheral 5-HT receptors attenuates colonic sensitivity to intraluminal distension

Tegaserod is a 5-HT(4) receptor partial agonist approved for the treatment of irritable bowel syndrome in women with constipation and in both men and women with chronic constipation. The efficacy of tegaserod is based on the importance of 5-HT(4) receptors regulating intestinal peristalsis and secretion, and possibly visceral sensory pathways. Our aim was to investigate the effect of tegaserod on colorectal sensitivity using models of normal and exaggerated responsiveness to colorectal distension (CRD). The visceromotor responses (VMR) to CRD at graded pressures (0-60 mmHg) were measured by the number of reflex abdominal contractions. Acute colorectal hypersensitivity was induced by intracolonic infusion of dilute acetic acid. Chronic hypersensitivity was observed in rats following spontaneous resolution of trinitrobenzenesulfonic acid-induced colitis. Rats with normosensitive colons served as controls. Tegaserod (0.1-10 mg kg(-1)) caused dose-dependent reduction of the VMR to CRD in control rats and in those with colonic hypersensitivity. 5-HT(4) antagonists reversed the effects of tegaserod in rats with normosensitive colons, and partially inhibited effects in rats with colonic hypersensitivity. Central administration of tegaserod had no inhibitory effect. These results support the assumption that colonic hypersensitivity could be normalized by tegaserod acting, at least in part, through peripheral 5-HT(4) receptors.

Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children

BACKGROUND

Anti-leukotrienes agents are currently being studied as alternative first line agents to inhaled corticosteroids in mild to moderate chronic asthma.

OBJECTIVES

To compare the safety and efficacy of anti-leukotriene agents with inhaled glucocorticoids (ICS) and to determine the dose-equivalence of anti-leukotrienes to daily dose of ICS.

SEARCH STRATEGY

We searched MEDLINE (1966 to Aug 2003), EMBASE (1980 to Aug 2003), CINAHL (1982 to Aug 2003), the Cochrane Airways Group trials register, and the Cochrane Central Register of Controlled Trials (August 2003), abstract books, and reference lists of review articles and trials. We contacted colleagues and international headquarters of anti-leukotrienes producers.

SELECTION CRITERIA

Randomised controlled trials that compared anti-leukotrienes with inhaled corticosteroids during a minimal 30-day intervention period in asthmatic patients aged 2 years and older.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality or trials and extracted trial data. The primary outcome was the rate of exacerbations requiring systemic corticosteroids. Secondary outcomes included lung function, indices of chronic asthma control, adverse effects and withdrawal rates.

MAIN RESULTS

27 trials (including 1 trial testing two protocols) met the inclusion criteria; 13 were of high methodological quality; 20 are published in full-text. All trials pertained to patients with mild to moderate persistent asthma. Only 3 trials focused on children and adolescents. Trial duration varied from 4 to 37 weeks. In most trials, daily dose of ICS was 400 mcg of beclomethasone or equivalent. Patients treated with anti-leukotrienes were 65% more likely to suffer an exacerbation requiring systemic steroids [Relative Risk 1.65; 95% Confidence Interval (CI) 1.36 to 2.00]. Twenty six (95% CI: 17 to 47) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra exacerbation. Significant differences favouring ICS were noted in secondary outcomes where()the improvement in FEV(1) reached 130 mL [13 trials; 95% CI: 50, 140 mL ]. Other significant benefits of ICS were seen for symptoms, nocturnal awakenings, rescue medication use, symptom-free days, and quality of life. Anti-leukotriene therapy was associated with 160% increased risk of withdrawals due to poor asthma control. Twenty nine (95% CI 20 to 48) patients must be treated with anti-leukotrienes instead of inhaled corticosteroids to cause one extra withdrawal due to poor control. Risk of side effects was not different between groups.

REVIEWERS' CONCLUSIONS

Inhaled steroids at a dose of 400 mcg/day of beclomethasone or equivalent are more effective than anti-leukotriene agents given in the usual licensed doses. The exact dose-equivalence of anti-leukotriene agents in mcg of ICS remains to be determined. Inhaled glucocorticoids should remain the first line monotherapy for persistent asthma.

Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma

BACKGROUND

Anti-leukotriene (AL) agents are being considered as 'add-on' therapy to inhaled corticosteroids (ICS), in chronic asthma.

OBJECTIVES

To examine the safety and efficacy of daily AL plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of AL when added to ICS in chronic asthma.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CINAHL (until August 2003), reference lists of review articles and trials, contacted international headquarters of AL manufacturers and looked at American Thoracic Society and European Respiratory Society meeting abstracts (1998 to 2003).

SELECTION CRITERIA

Randomised placebo-controlled trials of asthmatics aged two years and older with at least one month intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed quality and extracted data independently. Trials were grouped by asthma control at baseline (symptomatic or well-controlled) and dose of ICS in the control group (same or double).

MAIN RESULTS

Of 587 citations, 27 (25 adult and 2 paediatric) trials met inclusion criteria. Sixteen trials were published in full-text and 16 trials reported data in a way that allowed meta-analysis. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.64; 95% Confidence Interval (CI) 0.38 to 1.07). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.7 L/min; 95% CI 3.6 to 11.8 L/min) together with decrease in use of rescue short-acting beta2-agonist use (WMD 1 puff/week; 95%CI 0.5 to 2). With only 3 trials comparing the use of licensed doses of anti-leukotrienes with increasing the dose of inhaled glucocorticoids, no firm conclusion can be drawn about the equivalence of both treatment options. In ICS-sparing studies of patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD -21 mcg/d, 95%CI -65, 23 mcg/d), but it was associated with fewer withdrawals due to poor asthma control (RR 0.63, 95% CI 0.42 to 0.95).

REVIEWERS' CONCLUSIONS

The addition of licensed doses of anti-leukotrienes to add-on therapy to inhaled glucocorticoids brings modest improvement in lung function. Although addition of anti-leukotrienes to inhaled glucocorticoids appears comparable to increasing the dose of inhaled steroids, the power of the review is insufficient to confirm the equivalence of both treatment options. Addition of anti-leukotrienes is associated with superior asthma control after glucocorticoid tapering; although the glucocorticoid-sparing effect cannot be quantified at present, it appears modest.

Side-to-side weight-bearing asymmetry in subjects with low back pain

The purpose of this project was to determine if subjects with low back pain (LBP) exhibit greater side-to-side weight-bearing (WB) asymmetry compared to healthy control subjects without LBP. This study utilized an observational double cohort design and consisted of 35 subjects with LBP and 31 healthy control subjects. Side-to-side WB asymmetry was calculated as the average of the absolute value of the difference between the right and left lower extremity from three trials. The percentage of the average side-to-side WB asymmetry relative to the total body weight was calculated to normalize expected differences in magnitude of asymmetry based on a subject's total body weight. An 11-point numeric pain rating scale was used to represent the subject's current level of pain. Patients with LBP demonstrated significantly greater normalized side-to-side WB asymmetry than healthy control subjects (8.8% vs. 3.6%, respectively, P<0.001). In patients with LBP, higher magnitudes of side-to-side WB asymmetry were significantly associated with increased pain (r=0.39, P=0.021). In conclusion patients with LBP exhibited increased side-to-side WB asymmetry compared to healthy control subjects without LBP. This asymmetry was associated with increased levels of pain. This finding is relevant for planning future studies that will attempt to provide evidence for the construct validity of manipulation by determining if side-to-side WB asymmetry normalizes after a manipulation intervention and if this improvement is associated with improvements in pain and function.

Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma

BACKGROUND

Anti-leukotriene (AL) agents are being considered as "add-on" therapy to inhaled corticosteroids (ICS), in chronic asthma.

OBJECTIVES

To examine the safety and efficacy of daily AL plus ICS compared to ICS alone, and determine the corticosteroid-sparing effect of AL when added to ICS in chronic asthma.

SEARCH STRATEGY

We searched Medline, Embase, Cinahl (until September 2001), reference lists of review articles and trials, contacted international headquarters of AL manufacturers and ATS meeting abstracts (1998-2000).

SELECTION CRITERIA

Randomised placebo-controlled trials of asthmatics aged 2 years and older with at least one month intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed quality and extracted data independently. Trials were grouped by asthma control at baseline (symptomatic or well-controlled) and dose of ICS in the control group (same or double).

MAIN RESULTS

Of 438 citations, 13 (12 adult and 1 paediatric) trials met inclusion criteria. Seven were published in full-text. In symptomatic patients, addition of licensed doses of anti-leukotrienes to ICS resulted in a non-significant reduction in the risk of exacerbations requiring systemic steroids: Relative Risk (RR) 0.61; 95% Confidence Interval (CI) 0.36,1.05). A modest improvement group difference in PEF was seen (Weighted Mean Difference (WMD) 7.71 L/min; 95%CI 2.98, 12.44 L/min) together with beta2-agonist use (WMD= -0.32 puffs/day; 95%CI -0.0.08, -0.56). No trials that compared the use of licensed doses of anti-leukotrienes with doubling-dose of inhaled glucocorticoids could be pooled. In ICS-sparing studies in patients who were well controlled at baseline, addition of anti-leukotrienes produced no overall difference in dose of inhaled glucocorticoids (WMD -44.4 mcg/d, 95%CI -147.9, 59.0 mcg/d), but it was associated with fewer withdrawals due to poor asthma control (RR= 0.56, 95%CI 0.35, 0.89).

REVIEWER'S CONCLUSIONS

There is insufficient evidence to firmly support the use of licensed doses of anti-leukotrienes as add-on therapy to inhaled glucocorticoids. Addition of anti-leukotrienes to inhaled glucocorticoids may slightly improve asthma control, but the available data do not permit this strategy to be recommended as a substitute for increasing the dose of inhaled glucocorticoids. Addition of anti-leukotrienes may be associated with superior asthma control after glucocorticoid tapering, but a glucocorticoid-sparing effect cannot be quantified at present.

Outcomes after severe trauma at a northern Canadian regional trauma centre

OBJECTIVE

To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre.

DESIGN

A retrospective study.

SETTING

Sudbury General Hospital in northern Ontario.

PARTICIPANTS

All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12.

OUTCOME MEASURES

Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques.

RESULTS

Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle-traffic accidents in 48%, motor vehicle-nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.65.

CONCLUSIONS

In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.

Transesophageal echocardiographic recognition of an unusual complication of aortic valve endocarditis

Aortic valve endocarditis can cause complications due to involvement of the subaortic structures. These complications include satellite vegetations on the aortic regurgitant jet lesion sites, involvement of the anterior or posterior mitral valve leaflets in the form of aneurysms, perforation, and involvement of the mitral-aortic intervalvular fibrosa, namely abscess, aneurysm, and perforation into the left atrium or the pericardial sac. These complications can be identified accurately by echocardiography. We report an unusual case which demonstrates (1) coexistence of both mitral-aortic intervalvular fibrosa and mitral valve aneurysms, and (2) echocardiographic follow-up of a mitral valve aneurysm to perforation. These complications were recognized by transesophageal echocardiography and verified at surgery.

Use of brainstem auditory-evoked response testing to assess neurologic outcome following near drowning in children

OBJECTIVE

To determine a correlation between serial brainstem auditory-evoked response measurements and ultimate neurologic outcome in pediatric patients who suffered a cardiac arrest resulting from a submersion accident.

DESIGN

Inception cohort, prospective correlational study.

SETTING

A 15-bed pediatric ICU (within a 150-bed tertiary care pediatric hospital) admitting patients of all ages except nonsurgical neonates.

PATIENTS

All previously normal pediatric patients who suffered a cardiac arrest after a submersion accident. Patients evaluated: 111; patients studied: 89.

METHODS

Patients received serial brainstem auditory-evoked response testing within 6 hrs of resuscitation and then once daily for up to 10 days. Brainstem auditory-evoked response measurements included wave I-V interpeak latency, wave V amplitude, and wave I/V amplitude ratio. Upon discharge, patients were evaluated and classified into one of four neurologic outcome groups: normal, handicapped, vegetative, or dead. Patients classified into the handicapped group exhibited mild neurologic deficits after discharge. Vegetative patients were noninteractive with their environment and required full-time caretaker support. Serial brainstem auditory-evoked response measurements from the four outcome groups were compared with brainstem auditory-evoked response measurements obtained from a group of 39 healthy children of comparable age.

MAIN RESULTS

Patients who recovered neurologically intact manifested brainstem auditory-evoked response measurements that were similar to controls. Brainstem auditory-evoked response measurements in the handicapped outcome group were also normal after resuscitation but showed significant reduction in wave V amplitudes over the ensuing days. When compared with controls, patients with a vegetative outcome manifested abnormally prolonged wave I-V interpeak latencies, diminished wave V amplitudes, and large-wave I/V amplitude ratios following resuscitation. However, I-V interpeak latencies normalized within 24 hrs after resuscitation. I-V interpeak latencies were no different than controls until hospital day 3, at which time they became significantly prolonged. Patients who were declared brain dead or died from cardiovascular collapse exhibited very abnormal brainstem auditory-evoked response measurements on admission and until death. Wave V could not be detected on admission in 19/31 patients within this group.

CONCLUSIONS

Brainstem auditory-evoked response testing is useful as an aid in the assessment of neurologic outcome following submersion-induced cardiac arrest. However, standardization of brainstem auditory-evoked response testing and production of normative data are required before this modality can be more widely studied and applied.

Validity and reliability of a scale to assess fatigue

A visual analogue scale to evaluate fatigue severity (VAS-F) was developed and tested in a sample of 75 healthy individuals and a sample of 57 patients undergoing medical evaluation for sleep disorders. The scale consists of 18 items related to fatigue and energy, has simple instructions, and is completed with minimal time and effort. The VAS-F compares favorably with the Stanford Sleepiness Scale and the Profile of Mood States, and its internal consistency reliabilities are high. Healthy subjects demonstrated significant differences between their evening and morning scores on the VAS-F, while sleep-disordered patients did not.

Comparison of perceived needs of family members between registered nurses and family members of critically ill patients in intensive care and neonatal intensive care units

Using the Norris and Grove (1986) questionnaire of perceived needs of families of critically ill patients, 11 registered nurses working in the neonatal intensive care unit and 19 registered nurses working in the intensive care unit of two mid-northern community hospitals provided their perceptions of family needs. Their responses were compared with responses of family members of patients in the intensive care unit (n = 25) and the (n = 24). Results suggest that regardless of unit, registered nurses' perceptions of family needs are congruent. Family members collectively and by unit ranked their needs consistently higher and in some areas differently than did the registered nurses.

Seventy-six month experience with the Omniscience cardiac valve

Between August 1978 and September 1984, 440 patients were implanted with the Omniscience cardiac valve at three North American medical centers (210 aortic, AVR; 165 mitral, MVR; and 65 double valve replacements). Total follow-up was 1056 patient years; survivors were followed up to 76 months (mean 32), with 99% accountability. One hundred and eighty-six (42%) also underwent prior or concomitant major cardiac surgical procedures. Mean age was 56 +/- 12 years. Preoperatively, 3% were in New York Heart Association (NYHA) Class I, 18% II, 54% III, 26% IV. The 5 1/2 year actuarial survival rate for death from valve-related causes (thromboembolism, valve thrombosis, perivalvular leak) was 97% overall. The 5 1/2 year actuarial survival rate from all death causes was 78%. The complication rates, expressed as %/patient-year (endocarditis 0.7; anticoagulant-related hemorrhage 1.0; perivalvular leak 1.5; pannus/tissue overgrowth 0.6; and transient ischemic episode 1.2) demonstrate that advanced age at implant and additional major cardiac surgical procedures do not affect occurrence. Actuarial freedom from thrombotic complications (thromboembolism with residual deficit and valve thrombosis) at 5 1/2 years was 95% overall. Postoperatively, of 348 patients with known NYHA, 65% were in NYHA I, 28% II, 5% III, and 2% IV.

Functioning of the brain-stem auditory pathway in non-retarded autistic individuals

Functioning of auditory brain-stem pathways was examined in non-retarded autistic individuals (14-28 years of age). Functioning was assessed by recording ERPs (event-related brain potentials) generated by these auditory pathways. These ERPs were evoked by click stimuli and occurred within the first 8 msec following the onset of the click. To assess the ability of these early auditory pathways to process sensory stimuli of varying characteristics, we systematically varied click intensity, rate of stimulation, ear of stimulation, and polarity of clicks. The results show that non-retarded autistic individuals have normal functioning of the brain-stem auditory pathways which generate these ERPs: every autistic subject had normal ERPs. So, disorder in auditory brain-stem pathways which generate these ERPs is not necessary for autism to occur. The dysfunctioning neural systems directly responsible for autism in non-retarded individuals must be sought elsewhere. Ten of the autistic subjects in this study, whom we found to have normal auditory brain-stem ERPs, had previously been found to have abnormalities in longer latency cognitive ERP components (Courchesne et al. 1984, 1985). We conclude, therefore, that those abnormalities in longer latency components are not the downstream consequences of abnormalities in the structures generating the auditory brain-stem ERPs recorded in the present study.

Factors influencing thromboembolic complications in Omniscience cardiac valve patients

Clinical data were gathered over five years (650 patient-years) for all 155 aortic valve replacement, 125 mitral valve replacement and 46 double valve replacement patients implanted with the Omniscience cardiac valve prosthesis at three North American medical cent es. Mean age was 56 +/- 12 years, 80% were preoperatively in NYHA class III or IV, and 57% had previous or concomitant cardiac surgery. Data were evaluated for the incidence of thromboembolic complications. During the late postoperative period, transient ischaemic episodes occurred in six patients (0.92% per patient-year). The five-year actuarial thrombus-free rate for serious thromboembolic complications (valve thrombosis or thromboembolism with residual effects) for aortic valve replacement patients is 96% and 95% for mitral valve replacement patients. For patients experiencing any transient or serious thromboembolic complication, 35% had a compromise of coumadin anticoagulation shortly before the thromboembolic event, 60% had a history of atrial fibrillation, and 76% a history of rheumatic heart disease. Statistically, these rates are significantly higher compared with the original valve population. The low incidence of thromboembolic complications over this five-year clinical study demonstrates a commendable degree of safety and performance for the Omniscience valve.

Five-year clinical experience with the Omniscience cardiac valve

Clinical data on the Omniscience cardiac valve prosthesis (sizes 19 to 31 mm) were obtained from 326 patients (155, aortic valve replacement [AVR]; 125, mitral valve replacement [MVR]; and 46, double-valve replacement) during a five-year period (650 patient-years) with 96% accountability. Mean age was 56 +/- 12 years, and 40% (130) of the patients were 61 years old or older. Thirty-one percent (101) had prior or concomitant coronary artery bypass grafting procedures, 9% (28) had a previous malfunctioning prosthesis, and 17% (57) had other cardiac surgical procedures. Eighty percent were in New York Heart Association (NYHA) Functional Class III or IV preoperatively. Early mortality was 10% (34). Five-year actuarial thrombus-free rate is 96% for patients who underwent AVR and 95% for patients having MVR. Postoperatively, 89% (172/193) were in NYHA Class I or II, and 84% (163/193) improved by at least one Functional Class. A significantly high proportion of the postoperative hematological values fall within normal ranges: red blood cell count, 94% (176/187); hematocrit, 88% (166/188); and hemoglobin, 93% (176/190). Ninety-eight percent (287/292) are free from clinical anemia. Four of the 5 patients with clinical anemia had a preoperative history of this condition. Levels of lactic dehydrogenase in 3 patients suggested the probable presence of clinically significant hemolysis, although all 3 have normal hematological values. Actuarial five-year survival for patients who underwent AVR or MVR are similar (82% and 80%, respectively), indicating satisfactory and comparable levels of safety and performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Polytomography and congenital anomalies of the ear

Conventional radiography and even high resolution computerized axial tomography leave much to be desired in demonstrating the minutiae of the anatomy of the temporal bone. Multidirectional tomography remains the examination of choice radiographically in cases of congenital anomalies of the temporal bone. Details of the inner, middle and even external ear in the presence of atresia are more clearly delineated by this method than any other to data. Such information is of inestimable value to the surgeon in the diagnosis and surgical correction of anomalies of the temporal bone. Important features of the vestibule, semicircular canals, cochlea, facial nerve, internal auditory canal, temporomandibular joint, pneumatization of the temporal bone, tegmen, tympanic cavity, ossicles, oval and round windows, jugular bulb and carotid artery and the external ear canal are discerned most clearly by multidirectional tomography.

Topographic antigenic determinants recognized by monoclonal antibodies to sperm whale myoglobin

Monoclonal antibodies of high affinity (approximately 10(9) M-1) for sperm whale myoglobin were studied to pinpoint the antigenic determinants with which they interact. None of 6 different monoclonal antibodies tested reacted with any of the 3 CNBr cleavage fragments which encompass the whole sequence of myoglobin, an indication that they react with determinants present only on the native structure. To identify these sites, we compared the affinities of each antibody for a series of 14 mammalian myoglobins of known sequence and similar tertiary structure. Correlation of sequence differences with relative affinities allowed us, thus far, to identify critical antigenic residues recognized by 3 of the antibodies. Two of these antibodies recognize groups of residues which are far apart in primary structure but close together in the 3-dimensional structure of the native myoglobin molecule, i.e. topographic determinants. The third antibody distinguishes 140 Lys leads to Asn plus, probably, surface residues nearby. These determinants differ from previously reported antigenic sites on sperm whale myoglobin both in that they are topographic, rather than sequential, and in that almost all the critical residues recognized by these antibodies are outside the previously reported sites. Monoclonal antibodies are sensitive to subtle changes, e.g. Glu leads to Asp, in the antigenic site.

Ir genes of different high responder haplotypes for staphylococcal nuclease are not allelic

The Ir gene controlling high responsiveness to staphylococcal nuclease in the H-2d haplotype has been mapped to the I-A subregion, in contrast to that in the H-2k and H-2a haplotypes, which maps in the I-B subregion. The nonallelic high responder genes also confer differences in fine specificity on the antibodies produced. This nonallelism of Ir genes for the same antigen in different haplotypes is consistent with Ir gene mechanisms involving associative recognition of antigen plus Ia by T lymphocytes. It further suggests that products of different subregions can perform the same function.

Ir genes of different high responder haplotypes for staphylococcal nuclease are not allelic

The Ir gene controlling high responsiveness to staphylococcal nuclease in the H-2d haplotype has been mapped to the I-A subregion, in contrast to that in the H-2k and H-2a haplotypes, which maps in the I-B subregion. The nonallelic high responder genes also confer differences in fine specificity on the antibodies produced. This nonallelism of Ir genes for the same antigen in different haplotypes is consistent with Ir gene mechanisms involving associative recognition of antigen plus Ia by T lymphocytes. It further suggests that products of different subregions can perform the same function.

Properties of monoclonal antibodies specific for determinants of a protein antigen, myoglobin

Monoclonal hybridoma antibodies specific for the protein antigen sperm whale myoglobin were produced using hyperimmune spleen cells from mice with the genetic trait of high responsiveness to myoglobin. Antibodies from the several clones tested were found to produce linear Scatchard plots, as predicted for homogeneous antibodies, and to possess high affinities for the immunogen (KA congruent to 10(9) M-1). None of the monoclonal antibodies tested reacted with either fragment (1-55) or fragment (132-153) of sperm whale myoglobin. Competitive binding assays using human and horse myoglobins suggested that several of these monoclonal antibodies, which can readily distinguish these myoglobins, recognize different antigenic determinants on the myoglobin molecule. Studies using additional myoglobin sequence variants as competitors should be able to more closely define these antigenic determinants.

Evaluation of scoring system of the chest radiograph in cystic fibrosis: a collaborative study

A collaborative study including 16 cystic fibrosis centers, 22 observers, and more than 1,700 independent observations was undertaken to validate the reproducibility of a scoring system for evaluation of chest radiographs of patients with cystic fibrosis. Five large and 10 small centers were randomly selected by the project statistician. A total of 40 pairs (frontal and lateral) of chest radiographs representing varying degrees of severity was selected by a physician not involved in scoring. Duplicates of these films, identified only by code number, were scored independently by pediatric clinicians (small centers) and by both clinicians and radiologists (large centers). Data collection was complete for all observers. Analysis of the data confirms a moderately high degree of reproducibility by and among observers and indicates that this scoring system could be used in the assessment of patients with cystic fibrosis.

Clinical experience with the Lillehei-Kaster valve prosthesis

The Lillehei-Kaster valve was used in 215 patients over a 7-year period. The aortic valve was replaced in 81 of them. Hospital mortality was 21% (17 patients). Ten patients were lost to follow-up and long-term mortality was 5% (3 patients). The incidence of thromboembolism was 2.6 per 100 patient-years, and actuarial survival was 96% at 5 and 87% at 7 years. Mitral valve replacement was performed in 108 patients. Hospital mortality was 20% (22 patients), 24 patients were lost to follow-up, and long-term mortality was 13% (11 patients). The combined incidence of thromboembolism was 5.0 per 100 patient-years, and actuarial survival was 81% at 5 years and 75% at 7 years. In both groups, the majority of patients improved clinically. Fifteen patients had double-valve replacement, and 11 had coronary revascularization in addition to valve replacement.

The chest roentgenogram in cystic fibrosis: a new scoring system

A roentgenogram scoring system is presented that is useful in the evaluation and follow-up of patients with cystic fibrosis. The system has been shown to be reproducible by and between observers and to correlate significantly with results of pulmonary function tests, Shwachman-Kulczycki scores, and, in a short-term evaluation, morbidity.

Transmitting tissue in the pistil of tobacco: Light and electron microscopic observations

The pistil of tobacco (Nicotiana tabacum L. cv. Wisconsin 38) is comprised of two fused carpels. The stigma is bilobed, papillose, and at maturity is covered with a sticky exudate. The style is solid. Both stigma and style are made up of four tissue elements-epidermis, cortex, vascular, and transmitting tissue. Transmitting tissue in this species is chlorophyllous. Transmitting cells have thin primary walls and are separated by massive deposits of denselystaining amorphous material. The cells contain numerous mitochondria, dictyosomes, RER, amyloplasts, ribosomes, as well as crystal-containing microbodies and myelin-like formations. Observations are discussed in relation to other reports dealing with similar cell populations.