A statewide program providing colorectal cancer screening to the uninsured of South Carolina

BACKGROUND

Cancer screening rates are lowest in those without insurance or a regular provider. Since 2008, the Colorectal Cancer Prevention Network (CCPN) has provided open access colonoscopy to uninsured residents of South Carolina through established, statewide partnerships and patient navigation. Herein, we describe the structure, implementation, and clinical outcomes of this program.

METHODS

The CCPN provides access to colonoscopy screening at no cost to uninsured, asymptomatic patients aged 50-64 years (African Americans age 45-64 years are eligible) who live at or below 150% of the poverty line and seek medical care in free medical clinics, federally qualified health centers, or hospital-based indigent practices in South Carolina. Screening is performed by board-certified gastroenterologists. Descriptive statistics and regression analysis are used to describe the population screened, and to assess compliance rates and colonoscopy quality metrics.

RESULTS

Out of >4000 patients referred to the program, 1854 were deemed eligible, 1144 attended an in-person navigation visit, and 1030 completed a colonoscopy; 909 were included in the final sample. Nearly 90% of participants exhibited good-to-excellent bowel preparation. An overall cecal intubation rate of 99% was measured. The polyp detection rate and adenoma detection rate were 63% and 36%, respectively, with male sex and urban residence positively associated with adenoma detection. Over 13% of participants had an advanced polyp, and 1% had a cancer diagnosis or surgical intervention.

CONCLUSION

The CCPN program is characterized by strong collaboration with clinicians statewide, low no-show rates, and high colonoscopy quality. Future work will assess the effectiveness of the navigation approach and will explore the mechanisms driving higher adenoma detection in urban participants. Cancer 2018;124:1912-20. © 2018 American Cancer Society.

Services for pregnant drug users

Drug and alcohol misuse during pregnancy poses a threat to the health of both the developing foetus and the mother yet this complex clinical problem often falls between different stools within the health services. A mother would first have to recognise herself as a drug or alcohol misuser needing help before she came within the ambit of the addiction services. On the other hand, the obstetric agencies, even when they identify a drug problem, usually do not regard themselves as having a role. General practitioners are most likely to have an overall view and therefore to be in the best position to manage the problem. However, many misusers do not register with GPs and, despite calls to the contrary, GPs have not become more widely involved in the management of addiction.

Irradiation biology of male brown marmorated stink bugs: is there scope for the sterile insect technique?

PURPOSE

Brown marmorated stink bugs, Halyomorpha halys Stål (Hemiptera: Pentatomidae), are regularly intercepted, but there are few eradication tools. Currently, no sterile insect technique program exists for Hemiptera.

MATERIALS AND METHODS

Adult males were irradiated at 4-60 Gy, mated and their progeny reared for two generations, with mortality assessed at F₁ egg, F₁ adult and F₂ egg stages.

RESULTS

The F₁ eggs showed a dose response to irradiation between 4 and 36 Gy, with 97% sterility at 16 Gy, and higher doses producing complete egg mortality. Only rare F₁ survivors had progeny, but the F₂ generation showed identical responses between maternal and paternal lines; most egg batches showed either very low or very high mortality. Irradiation with 16 Gy resulted in 98.5% sterility, cumulative over F₁ and F₂.

CONCLUSIONS

Lack of a dose response at the F₂ generation precludes the use of irradiation-induced inherited sterility. The conventional sterile insect technique appears possible by irradiation of males from ∼12 to 16 Gy. The effect of radiation dose on females is not known, thus we cannot conclude whether bi-sex release is feasible so for now the release of males only is recommended. More work is needed on the competitive fitness of irradiated males, and logistics such as mass rearing or field collection, in order to determine the feasibility of the approach.

Race and Prevalence of Large Bowel Polyps Among the Low-Income and Uninsured in South Carolina

BACKGROUND

Compared to whites, blacks have higher colorectal cancer incidence and mortality rates and are at greater risk for early-onset disease. The reasons for this racial disparity are poorly understood, but one contributing factor could be differences in access to high-quality screening and medical care.

AIMS

The present study was carried out to assess whether a racial difference in prevalence of large bowel polyps persists within a poor and uninsured population (n = 233, 124 blacks, 91 whites, 18 other) undergoing screening colonoscopy.

METHODS

Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45-64 years (blacks) or 50-64 years (whites, other). We examined the prevalence of any adenoma (conventional, serrated) and then difference in adenoma/polyp type by race and age categories.

RESULTS

Prevalence for ≥1 adenoma was 37 % (95 % CI 31-43 %) for all races combined and 36 % in blacks <50 years, 38 % in blacks ≥50 years, and 35 % in whites. When stratified by race, blacks had a higher prevalence of large conventional proximal neoplasia (8 %) compared to whites (2 %) (p value = 0.06) but a lower prevalence of any serrated-like (blacks 18 %, whites 32 %; p value = 0.02) and sessile serrated adenomas/polyps (blacks 2 %, whites 8 % Chi-square p value; p = 0.05).

CONCLUSIONS

Within this uninsured population, the overall prevalence of adenomas was high and nearly equal by race, but the racial differences observed between serrated and conventional polyp types emphasize the importance of taking polyp type into account in future research on this topic.

Abstract B85: Racial differences in the risk of serrated polyps and conventional adenomas in a younger aged, uninsured population in South Carolina

Compared to European Americans (EA), African Americans (AA) have higher colorectal cancer (CRC) incidence and are diagnosed with CRC at younger ages. The reasons for these disparities are poorly understood, but one contributing factor could be reduced access to high-quality preventative care. To address CRC disparities, this study assessed whether a racial difference in risk of large bowel polyps (precursors to most CRC) persists within a younger-aged, uninsured population in South Carolina (SC) undergoing screening colonscopy. We analyzed data from a multi-site statewide CRC screening program in SC to explore the risk of large bowel polyps among AA and EA. Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45-64 years (AA) or 50-64 years (EA). Using generalized linear regression, we estimated risk ratios and 95% confidence intervals (CI) as measures of the association between race and risk for one or more conventional adenomas or serrated polyps adjusting for age, sex, family history of CRC, and clinical site. Serrated polyps (SP) were defined as one or more hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed adenomatous polyps. SP were first classified in a single category since not all project pathologists used up-to-date pathologic terminology and there was a high-level of variability among clinical sites in use of newer SP categories (i.e., sessile, traditional adenomas). Serrated adenomas included any SP with serrated adenomatous features (sessile, traditional, or mixed). Advanced SP were defined as SP with large size (an estimated ≥ 1 cm). Conventional adenomas (CA) were defined as tubular, tubulovillous, or villous polyps. Advanced CA were defined as adenomas with at least 25% villous component (TVA), high-grade dysplasia (HGD), or large size. We also stratified polyps separately according to colonic region (proximal or distal colorectum), large size, and advanced CA histology (TVA, HGD). Of the 237 subjects enrolled (127 AA, 91 EA, 19 other), 233 had a complete exam (i.e., to the cecum). Our results suggested a lower risk of SP among AA compared to EA: any SP (RR 0.50 (95% CI 0.30-0.84)), any serrated adenoma (RR 0.35 (95% CI 0.11-1.14)), and any large SP (RR 0.27 (95% CI 0.09-0.85)). Although not always statistically significant, the trend in the results indicate that the risk of CA was higher in AA compared to EA: any CA 1.17 (95% CI 0.77-1.79), large CA 2.16 (95% CI 0.70-6.66), proximal large CA 4.24 (95% CI 1.0-18.01), and any advanced CA 1.38 (95% CI 0.55-3.42). In patients under 55 years of age (median age), AA compared to EA had higher risk of advanced CA histology lesions RR 4.11 (95% 1.05 -16.11), but otherwise risks were similar in the age groups. Overall, our findings suggest that it is important to consider type of polyp and age when assessing risk in different racial groups. Our results in this unique study population are consistent with an earlier study showing that AA have a lower risk of metachronous SP and among younger patients, an increased risk of conventional adenomas, especially advanced lesions. The persistence of these observations within a study population comprised of all medically underserved individuals implies that the unique features of the epidemiology of colorectal neoplasia in AA cannot be completely attributed to access to care barriers.

Citation Format: Kristin Wallace, Anthony Alberg, Bridgette Blankenship, Heather Brandt, Renay Caldwell, James Dunn, Patricia Hegedus, Brenda Hoffman, Courtney Marsh, March Seabrook, Marylou Stinson, Annie Thibault, Franklin Berger. Racial differences in the risk of serrated polyps and conventional adenomas in a younger aged, uninsured population in South Carolina. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B85.

Correlation between Bacillus subtilis scoC phenotype and gene expression determined using microarrays for transcriptome analysis

The availability of the complete sequence of the Bacillus subtilis chromosome (F. Kunst et al., Nature 390:249-256, 1997) makes possible the construction of genome-wide DNA arrays and the study of this organism on a global scale. Because we have a long-standing interest in the effects of scoC on late-stage developmental phenomena as they relate to aprE expression, we studied the genome-wide effects of a scoC null mutant with the goal of furthering the understanding of the role of scoC in growth and developmental processes. In the present work we compared the expression patterns of isogenic B. subtilis strains, one of which carries a null mutation in the scoC locus (scoC4). The results obtained indicate that scoC regulates, either directly or indirectly, the expression of at least 560 genes in the B. subtilis genome. ScoC appeared to repress as well as activate gene expression. Changes in expression were observed in genes encoding transport and binding proteins, those involved in amino acid, carbohydrate, and nucleotide and/or nucleoside metabolism, and those associated with motility, sporulation, and adaptation to atypical conditions. Changes in gene expression were also observed for transcriptional regulators, along with sigma factors, regulatory phosphatases and kinases, and members of sensor regulator systems. In this report, we discuss some of the phenotypes associated with the scoC mutant in light of the transcriptome changes observed.

Does single versus stepped curing of composite resins affect their shear bond strength?

BACKGROUND

Shrinkage occurs during polymerization of all resin composites, affecting not only the physical properties of the composites but also the marginal integrity of the restoration. Stepped photo-polymerization, in contrast to single-cure photo-polymerization, is said to minimize this shrinkage. The thickness of the increments of resin composite being cured may also be a factor in final shear bond strength. This study compared the shear bond strength resulting from these two curing methods with resin composites of various thicknesses.

METHODS

Resin composite in increments of 1.5, 3 and 4.5 mm thickness, cured by stepped or single-cure photo-polymerization, was bonded to human third molar dentin with either the Scotchbond Multipurpose adhesive system or the Singlebond adhesive system. Each experimental group consisted of 12 specimens. After 7 days of storage in water, shear bond strength was tested to failure, and the mode of failure was recorded.

RESULTS

The thickness of the resin composite and the method of curing had no significant effect on shear bond strength for bonds mediated by Scotchbond Multipurpose adhesive, but significantly lower shear bond strength was recorded for bonds mediated by Singlebond adhesive for resin composite 4.5 mm in thickness. With thicker resin composite, there was a tendency toward a greater proportion of adhesive cohesive bond failures.

CLINICAL SIGNIFICANCE

The stepped photo-polymerization system of curing appears to offer no advantages over single-cure photo-polymerization, except that the former reportedly improves marginal adaptation and reduces marginal leakage. These results suggest that increments of resin composite to be cured by either method should be no thicker than 2 mm, particularly when the bond is mediated by a single-bottle adhesive.

Recall Rummy: Learning Can be Fun

BACKGROUND

Nurse educators are continuously seeking creative methods to teach nursing skills. Continuing education programs have adapted and used television game show themes as effective teaching strategies.

METHOD

The traditional card game of rummy has been modified into a creative learning technique for entertaining and reinforcing skill techniques for nurses practicing in a clinical setting.

CONCLUSION

Imagination and creativity are important assets for planning and teaching skills that relate to the practice of nursing. Recall Rummy presents one such approach to teaching nursing skills.

Survival and risk factors for death after cardiac transplantation in infants. A multi-institutional study. The Pediatric Heart Transplant Study

BACKGROUND

Despite the increasing application of cardiac transplantation in infants, reported survival rates vary, and risk factors for death are poorly understood.

METHODS AND RESULTS

To examine early survival and risk factors for death in infants (< 1 year of age) undergoing cardiac transplantation, 141 infants (36 < 1 months of age) underwent primary cardiac transplantation between January 1, 1993, and January 1, 1995, at 23 centers in the Pediatric Heart Transplant Study (PHTS). Diagnoses were hypoplastic left heart syndrome (66%), other congenital heart disease (17%), cardiomyopathy (14%), and other (3%). Actuarial survival after cardiac transplantation was 84% at 1 month, 70% at 1 year, and 69% at 2 years, with the greatest hazard for death within the first 3 months. The principal cause of death was early graft failure in 20 patients (52% of deaths), infection in 10 (26% of deaths), and rejection in 4 (10%). On the basis of multivariate analysis, risk factors for early mortality were history of previous sternotomy (P = .0003), nonidentical blood type donor (P = .01), recipient non-blood group A (P = .02), and donor cause of death other than closed head trauma (P = .04). Diagnosis at listing, waiting time (mean, 1.3 months), graft ischemic time (mean, 228 minutes; range, 68 to 479 minutes), and recipient ventilatory or inotropic support at listing were not predictive for mortality after transplant.

CONCLUSIONS

The higher mortality rate observed with infant heart transplantation is due to a higher mortality within the first month after transplantation as a result of early graft failure. Strategies to improve donor heart function at implantation would have the greatest impact on survival after infant cardiac transplantation.

Dynamic three-dimensional echocardiographic reconstruction of congenital cardiac septation defects

Dynamic three-dimensional echocardiographic reconstructions of 27 cardiac septation defects were performed in 19 sedated infants and children. Using a subxiphoid rotational scanning approach, complete visualization of the entire shape and breadth of the defect was attained in 11 of 16 ventricular septal defects and 9 of 11 atrial septal defects. This technique enabled the operator to cut slices from the three-dimensional block of echocardiographic data in order to present septation defects in a region- or lesion-oriented fashion. Poor baseline two-dimensional image quality and certain small septation defects that were readily obscured by nearby structures led to inadequate three-dimensional reconstructions. The application of dynamic three-dimensional echocardiography for assessment of cardiac septation defects uniquely provided (1) the ability to present en face views of atrial and ventricular septal defects; and (2) a means by which intracardiac anatomy can be displayed in a region- and lesion-oriented fashion for interventional and surgical planning purposes.

The ampS-nprE (124 degrees-127 degrees) region of the Bacillus subtilis 168 chromosome: sequencing of a 27 kb segment and identification of several genes in the area

A stretch of DNA approximately 27 kb in length, adjacent to the nprE gene of Bacillus subtilis, has been sequenced. The sequenced fragment carries a total of 23 ORFs. Of these, 15 could be assigned probable functions based on homologies to characterized genes either in B. subtilis or in other organisms. The sequencing of this region has also allowed us to assign to this area adeC and strB, previously located on the other side of nprE, between nprE and the pyr operon.

Cost-benefit analysis of an automated medication system

Automated medication distribution systems have helped solve issues of efficiency and effectiveness. Cost-benefit analysis conducted by nursing and pharmacy departments can help to objectify the decision to adopt this technology.

Superoxide dismutase improves posttraumatic cortical blood flow in rats

Oxygen free radicals, such as the superoxide anion, are known to mediate damage to the cerebral microcirculation following traumatic brain injury. The purpose of this study was to determine if superoxide dismutase (SOD), a scavenger of superoxide anion, could alter posttraumatic cortical blood flow. Following barbiturate anesthesia, rats were surgically prepared for moderate fluid percussion brain injury. Cortical blood flow contralateral to the site of injury was measured using laser-Doppler flowmetry. Laser-Doppler flowmetry assesses flow by measuring cell volume and velocity, which are multiplied electronically to give flow. Starting 10 min before injury, animals received either superoxide dismutase (24,000 U/kg bolus, followed by continuous infusion of 1600 U/kg/min) or an equal volume of saline. Blood pressure, heart rate, and cortical blood flow were measured up to 1 h posttrauma. Rats receiving superoxide dismutase had significantly higher cortical blood flow posttrauma (F = 6.91, p < 0.02). One hour posttrauma, the blood flow in SOD-treated rats was 89 +/- 8% of preinjury baseline, whereas this value was only 66 +/- 6% of control in saline-treated rats. SOD caused not only greater blood velocity but also less reduction in cortical blood volume after injury. There were no significant differences between the groups with respect to blood pressure or heart rate. This study further supports the role of oxygen radical-mediated cerebrovascular dysfunction following traumatic brain injury and is the first to show the beneficial effect of SOD on cortical blood flow following fluid percussion brain injury.

Echocardiographic analysis of rejection in the infant heart transplant recipient

Eleven children who received transplants at less than 2 years of age underwent 59 echocardiograms at the time of endomyocardial biopsy for the assessment of the ability of echocardiography to predict acute rejection in the infant heart transplant recipient. Two patients died of acute rejection and autopsy findings were compared with premortum echocardiograms. Biopsy specimens were graded as no rejection (n = 46), mild rejection (cellular infiltrate, n = 5), or moderate-severe rejection (myocyte necrosis/edema, n = 8). Echocardiographic indexes measured included the following: left ventricular mass, left ventricular volume, ejection fraction, heart rate, and peak rate of posterior wall thinning. Compared with controls, patients during mild rejection had slower posterior wall diastolic thinning (p < 0.01). No significant change was noted in left ventricular mass until endomyocardial biopsy specimens showed severe rejection. No significant changes were noted in heart rate or ejection fraction in any of the groups. In conclusion, decrease in the peak rate of posterior wall diastolic thinning may be a sensitive indicator of acute rejection in the infant heart transplant recipient.

Cardiac transplantation in infants and children

Cardiac transplantation has become a more frequently used therapeutic modality for select cardiac pathology in infants and children. Since June 1986, 30 pediatric patients (19 male and 11 female) ranging in age from 4 days to 15 years (11 < or = 1 month old) have undergone orthotopic cardiac transplantation at our institution. Indications included idiopathic cardiomyopathy (n = 8), hypoplastic left heart syndrome (n = 13), and other forms of complex congenital heart disease (n = 9). There have been four operative and three late deaths only in the groups with hypoplastic left heart syndrome and other forms of complex congenital heart disease. Cumulative survival is 77% after a mean follow-up of 30 months (range, 6 to 77 months). Three operative deaths were attributable to pulmonary hypertension, and the other was due to pulmonary hemorrhage. Two late deaths were secondary to allograft rejection, and the third was due to infection. There has been uniform survival in the group with idiopathic cardiomyopathy, and intermediate-term survival rates are 78% and 62% in the groups with complex congenital heart diseases and hypoplastic left heart syndrome, respectively (p = 0.15). Although longer-term results are necessary, orthotopic cardiac transplantation appears to be an acceptable mode of therapy for endstage heart disease in the pediatric age group and technically can be performed despite complex malformations of the great arteries or atria.

Feasibility of generating hemodynamic pressure curves from noninvasive Doppler echocardiographic signals

OBJECTIVES

This study was designed to determine the feasibility of Doppler generation of accurate, complete right ventricular and pulmonary artery pressure curves in patients with Doppler-measurable tricuspid and pulmonary regurgitation.

BACKGROUND

Doppler-derived flow velocities have been used to assess right ventricular systolic pressure; pulmonary artery systolic, diastolic and mean pressures, and left ventricular systolic and diastolic pressures. Instantaneous gradient across any area of discrete narrowing is accurately derived using the simplified Bernoulli equation (4V2). Invasive catheterization is currently the only means of generating intracardiac pressure curves. Noninvasively derived pressure curves using Doppler echocardiography would be a considerable advance in the assessment of normal and pathologic cardiac hemodynamics.

METHODS

Right ventricular and pulmonary artery pressure curves were generated in 18 of 22 patients with measurable tricuspid and pulmonary valve regurgitation using superimposition of Doppler-measured tricuspid and pulmonary valve blood flow velocities on an assumed right atrial pressure. Doppler-measured right ventricular and pulmonary artery pressure curves were compared with simultaneous catheterization-measured curves.

RESULTS

Doppler-derived pulmonary artery systolic pressure (Doppler PAP) correlated with simultaneous catheter-measured pulmonary artery pressure (Cath PAP) by the equation Doppler PAP = 0.92(Cath PAP) + 4.5, r = 0.98. Other Doppler-derived pressure measurements that correlated at near identity with the catheterization-measured corresponding measurement include Doppler-derived pulmonary artery mean pressure (Doppler mean PAP) [Doppler mean PAP = 0.85(Cath mean PAP) + 2.6, r = 0.97], and Doppler-derived right ventricular pressure (Doppler RVP) [Doppler RVP = 0.84(Cath measured RVP) + 7.9, r = 0.98]. Doppler-derived pulmonary, artery diastolic pressure (Doppler PAP diast) did not correspond as well in this study [Doppler PAP diast = 0.45(Cath PAP diast) + 6.6, r = 0.83].

CONCLUSIONS

Clinically usable right ventricular and pulmonary artery pressure curves can be derived by superimposing Doppler-measured tricuspid and pulmonary valve blood flow velocities in patients with tricuspid and pulmonary valve regurgitation.

Triple-drug immunosuppression for heart transplantation in infants and children

Triple-drug immunosuppression with OKT3 induction is effective rejection prophylaxis in pediatric cardiac allograft recipients. The concerns regarding prevalent lymphoproliferative disease, growth retardation, cytomegalovirus, and other opportunistic infections have not been realized. Since June 1986, 34 pediatric patients, 23 males and 11 females, (age 4 days to 15 years) have undergone orthotopic heart transplantation at our institution. Fifteen patients were less than 6 months old and 13 had type I or II hypoplastic left heart syndrome. There have been four (12%) operative and four (12%) late deaths and a survival rate of 76% after a mean follow-up of 33 months (range, 1 to 82 months). The only deaths attributed to allograft rejection occurred in two newborn recipients (2 and 10 months after surgery) who neither received maintenance steroids nor underwent routine biopsy. The only death from infection (pneumococcus) occurred 6 months after surgery in a 4-year-old patient who was not known to be asplenic. Of the 27 long-term (> 1 year) survivors, 17 (68%) had an average of two rejection episodes during the follow-up period, 10 patients (32%) have been free of graft rejection, and 26 patients (96%) have not experienced a cytomegalovirus infection despite OKT3 induction therapy. Two patients developed lymphoproliferative disease, one of whom was successfully treated by transient reduction of immunosuppression. The other patient died 13 months after transplantation of a lymphoma of the central nervous system. All survivors have demonstrated satisfactory increases in mean height and weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost effective EMIT assays, for drugs of abuse in urine, using the Eppendorf EPOS analyser

Laboratories with an increasing work load of drug abuse testing require high turnover techniques at low cost. Syva's EMIT system is suitable for modification onto modern automated instrumentation and, with reagent dilution, costs can be significantly reduced. We describe the modification of these assays onto the Eppendorf EPOS analyser which can process 300 samples an hour at a cost of 13p per test.

Adenocarcinoma of the small intestine in Crohn's disease: a unique finding

Development of adenocarcinoma of the small bowel is rare. We present this report of a patient with a long-standing history of Crohn's disease who was found to have the 95th reported case of adenocarcinoma developed in the presence of Crohn's. The unique feature of this case is the finding of two distinctly separate carcinomas in the same surgical specimen. With report of this case and a review of the literature, certain characteristics are presented in hopes of raising suspicions sufficiently to detect this malady at an earlier stage.

Congenital aneurysm of the left atrial wall in infancy

A 5-month-old male infant with congenital left atrial aneurysm is reported. The youngest patient previously reported was 2 1/2 years old. This case is unusual because the patient was an infant and because of the degree of mitral insufficiency and acute cardiac decompensation observed in the patient.

A capillary column gas-chromatographic method for the identification of drugs of abuse in urine samples

This paper describes the application of capillary column gas liquid chromatography (GLC) to the analysis of urine samples for drugs of abuse. A simple basic extraction into butylacetate is followed by temperature programmed analysis from 90 degrees C to 310 degrees C to provide a comprehensive screen for basic drugs. Retention data are presented for approximately 300 compounds. The use of capillary column GLC is compared with packed column methods used previously in this laboratory. The reproducibility of retention data and sensitivity of this analysis for several commonly encountered drugs are presented.

Management of asymptomatic intracardiac missiles using echocardiography

A child sustained a low-velocity airgun pellet injury to the left ventricle. No cardiovascular compromise was produced. The foreign body was localized by two-dimensional echocardiography to the left ventricular chamber near the mitral valve, and subsequently removed through a left atriotomy incision. In asymptomatic patients, missiles clearly embedded within a chamber wall may be observed; all others should be removed. Two-dimensional echocardiography is recommended for localization.

Surgery for discrete subvalvular aortic stenosis: actuarial survival, hemodynamic results, and acquired aortic regurgitation

Discrete membranous subaortic stenosis (DMSS) accounts for 8 to 30% of congenital left ventricular outflow obstruction. The immediate effectiveness of surgical resection of this discrete obstructing membrane has been well documented, but little has appeared regarding late clinical and hemodynamic follow-up. Fifty-three patients with DMSS underwent operation at our institution from 1957 to 1983. Most (78%) were symptomatic, 79% had left ventricular hypertrophy (LVH) by electrocardiogram, and 92% had roentgenographic evidence of cardiomegaly preoperatively. Catheterization revealed a mean preoperative left ventricular-aortic gradient of 89 mm Hg. Twenty-eight patients had associated aortic insufficiency (AI) on the initial aortogram. Seven patients acquired AI in the interim between the first and second preoperative catheterization. Our patients have been followed for up to 12 years postoperatively. There have been 2 early and 3 late deaths. (Actuarial analysis revealed 5- and 10-year survival of 95% and 83%, respectively.) Seventy-one percent of the previously symptomatic patients noted relief of their preoperative complaints, and 45% of those with LVH had a regression in voltage. Cardiomegaly as determined by chest roentgenogram decreased in 45%. The left ventricular-aortic gradient fell to an average of 35 mm Hg a year postoperatively. Surgical treatment of congenital subvalvular aortic stenosis is effective in reducing the preoperative symptoms and the left ventricular-aortic gradient. It appears that DMSS causes AI.

Pharmacologic cardioversion of intrauterine supraventricular tachycardia. A case report

Fetal supraventricular tachycardia was converted successfully with digoxin, and the congestive heart failure resolved. Previous case reports of fetal supraventricular tachycardia have established guidelines for its treatment; digoxin remains the drug of choice.

Acute trazodone poisoning: clinical signs and plasma concentrations

A total of 70 patients presenting with suspected acute trazodone poisoning were notified to the Poisons Unit (National Poisons Information Service for England) from August 1980 until March 1983. Detailed follow-up information was obtained on 41 patients, 22 of whom were thought to have ingested trazodone alone. In these latter patients drowsiness (11), ataxia (5), nausea/vomiting (4) and dry mouth (2) were the manifestations of toxicity reported most frequently, only 2 patients became unconscious (grade 2 or 3 coma), and all recovered uneventfully with no more than minimal supportive therapy. The presence of trazodone was confirmed in 8 out of 9 patients from whom specimens (blood and urine) were received. The highest plasma trazodone concentrations (15 and 19 mg/l, respectively) were both associated with only drowsiness and ataxia. However, in 2 further patients moderate plasma trazodone concentrations (4.2 and 8.2 mg/l, respectively) were associated with deep (grade 3-4) coma, although 1 of these latter patients had also ingested ethanol (plasma concentration 3.0 g/l). Although acute trazodone poisoning does not appear to be associated with cardiac arrhythmias or convulsions, these results emphasise that drowsiness and ataxia are commonly encountered, while coma may occur in severe cases. The possible contribution of metabolites of trazodone to toxicity and the potentiating effect of co-ingested drugs or alcohol must be remembered.

Albumin influences sulfobromophthalein transport by hepatocytes of each acinar zone

To determine whether profiles of decreasing concentration were generated among hepatocytes of the liver acinus during the transport of sulfobromophthalein sodium (BSP), rat livers were perfused with various concentrations of this dye (10 microM to 1 mM) in the presence and absence of albumin. After steady-state conditions for the biliary secretion of BSP had been attained, pieces of liver were rapidly frozen. Following the alkalinization of cryostat-cut sections, the relative concentration of BSP in hepatocytes of each zone and the effect of albumin on this localization were quantitated by microspectrophotometry. The results showed that BSP, perfused in the absence of albumin, was efficiently extracted by the liver (95% on a single pass), generating distinct profiles of decreasing cellular concentration from zone 1 to zone 3 at every concentration of BSP. However, the addition of albumin to the perfusate greatly reduced the extraction of BSP from the sinusoidal compartment and resulted in the abolition of the differences in BSP content between hepatocytes of zone 1 and zone 3. These results represent a direct demonstration that, as predicted by mathematical modeling, binding of BSP to albumin indeed results in a more homogeneous distribution of BSP within the liver acinus. A simple and direct microspectrophotometric method is therefore available to follow the changes in the relative concentration of BSP among the hepatocytes of the various acinar zones.

Toxicological investigations in the detection of drug-induced disease in elderly patients

1 During 1978--1980 general toxicological investigations were performed on specimens from 211 patients (62 male, 149 female) aged 65 years and over. 2 The investigations were an important factor in establishing the diagnosis in 32 of 91 (28 male, 63 female aged 65--92 years, median 73 years) poisoned patients, most (75) of whom had deliberately taken overdoses. 3 Seventy-one patients were severely poisoned (grade 3--4 coma) and 10 died. Benzodiazepines (49%) and barbiturates (43%) were the drugs encountered most frequently, although 54% had ingested more than one pharmaceutical preparation. 4 In the survivors the depth of coma was usually greatest in patients poisoned principally with barbiturates, whilst the duration of coma and the incidence of respiratory complications were greater in those poisoned with benzodiazepines. However, there was considerable variability in the depth and duration of coma associated with a given initial plasma concentration within both groups. 5 Although general toxicological investigations can provide useful diagnostic information when poisoning is suspected in elderly patients, unequivocal interpretation of the results obtained is not always possible.

Spondylocostal dysostosis associated with anal and urogenital anomalies in a Mennonite sibship

Spondylocostal dysostosis, anal atresia, and urogenital anomalies were observed in two male infants of a consanguineous Mennonite couple. A careful review of previously reported syndromes of severe vertebral abnormalities and/or imperforate anus suggests that our patients have a previously undescribed recessive disorder that should be included in the differential diagnosis of rib and vertebral anomaly syndromes.

Improved results in newborns undergoing coarctation repair

Among 172 children who underwent repair of coarctation of the thoracic aorta from June 1, 1967, to June 1, 1979, there were 50 who were less than 6 weeks old. A review was undertaken to assess mortality and postoperative residual hypertension in this newborn age group. Forty-five (90%) had one or more associated congenital cardiac lesions, which were repaired or paliated at the time of coarctation repair. The three most common associated lesions were patent ductus arteriosus (74%), atrial septal defect (74%), and ventricular septal defect (62%). Thirty-one newborns underwent resection with parimary end-to-end repair with 8 deaths (26%), and 18 underwent Dacron patch angioplasty and 1 underwent subclavian angioplasty with 4 deaths (21%). Of the 38 survivors, 36 (95%) had good pedal pulses on postoperative clinical examination 3 months to eleven years postoperatively. Seventeen (45%) had upper and lower extremity blood pressure measured; 2 (5%) showed residual upper extremity hypertension (greater than 2 standard deviations above the mean and a gradient less than 20 mm Hg). One of these 2 patients has undergone repeat repair. Based on this low mortality and infrequent need for repeat repair, we advocate aggressive early operation and judicious use of palliative procedures in newborns, when indicated, for associated defects.

Divalent cation stimulation of in vitro fibre assembly from epidermal keratin protein

Keratin was extracted from purified cornified cells of newborn rats in Tris-HCl-buffered 8 M urea containing beta-mercaptoethanol. Microfilaments were assembled in vitro by reducing the ionic strength of buffer and the urea concentration. One millimolar concentration of KCl and NaCl did not affect filament formation, but the same concentration of divalent cations greatly altered this process. CaCl2 and MgCl2 induced gelation of keratin by formation of bundles of birefringent macrofilaments. ZnCl2, CuSO4 and HgCl2 formed greater numbers of macrofilaments and the protein aggregated.

Activity of alpha-1, 4-glucosidase in furazolidone-induced glycogenosis

Furazolidone (FZ) at 700 and 800 p.p.m. was added to feed mixtures fed turkey poults two and three weeks posthatching, respectively, to induce acute experimental cardiomyopathy. Poults in the control pen received the same ration but without FZ. From EKG data obtained at 2, 4, and 5 weeks of age, control unaffected and experimental affected poults were selected for sacrifice. Poults were sacrificed by cervical dislocation and appropriate samples of hepatic tissue were removed for assays of activity of alpha-1, 4-glucosidase. Results indicate that enzyme activity in affected FZ-treated poults is similar to that in unaffected control poults. Lack of significant differences in activity of this lysosomal enzyme suggests that FZ-induced glycogenosis may be related to the adult form of idiopathic generalized glucogenosis, the etiology of which remains unidentified.

Ochratoxin A toxicosis in swine

Ochratoxicosis was induced in young female swine by a diet contaminated with a rice culture of Aspergillus ostianus that contained ochratoxin A and by daily oral doses of 2.0 or 1.0 mg/kg body weight pure ochratoxin A. Mycotoxicosis was characterized early by depression and reduction in feed intake and loss of body weight, followed by diarrhea, polyuria, polydipsia and dehydration. The pigs given pure ochratoxin A were dead or moribund in 5 to 6 days. Packed cell volume, hemoglobin, total plasma protein, and blood urea nitrogen were increased. Progressive leukocytosis, neutrophitia and moderate left shift in the differential count occurred. Concentrations of lactic dehydrogenase, isocitric dehydrogenase and glutamic-oxalacetic transaminase in the serum and urine were increased by the fourth to sixth day, but only the increase in urinary concentrations was significant. Gross findings included dehydration, enteritis, pale tan discoloration of the liver, and edema and hyperemia of the mesenteric and other lymph nodes. Microscopic lesions were most frequent and severe in the kidney and gastrointestinal tract. Necrosis of renal tubular epithelium was most frequent in the convoluted tubules. Many renal tubules were dilated. The intestinal lesions were focal and necrotizing and occurred in mostanat omic regions. Fatty change was demonstrated in most of the livers. In lymphoid tissues the changes were edema, hyperemia and focal necrosis of lymphocytes within germinal centers and around follicles.

Effects of promethazine-hydrochloride on human polymorphonuclear leukocytes

Promethazine hydrochloride at a concentration of 0.033 mg/ml has pronounced effects on leukocyte metabolism and function. The drug inhibits the phagocytosis-induced increases in O(2) consumption and hexose monophosphate shunt activity. Associated with these effects is an inhibition of the iodination of zymosan particles and an inhibition of bacterial killing by the cell. At least two mechanisms appear to be involved. Many of the effects can be explained by an inhibition of phagocytosis, but promethazine also inhibits the decarboxylation of amino acids and iodide fixation in a cell-free system, indicating a specific effect on metabolism. These results may partially account for the action of the drug in ameliorating the effects of erythroblastosis.