The risk to the cutaneous nerve branches in the anterior (Wagner) and snuff-box approaches to the trapezium: a cadaveric study

We compared the risk with the subcutaneous nerves with the anterior (Wagner) and snuff-box approaches to the trapezium in cadavers. Branches that crossed tattooed incision markings or lay within 1 cm of the markings were identified on six matched pairs of fresh-frozen cadaveric hands. Their distance from the proximal end of the incision was recorded. For anterior incisions, there were 20 vulnerable branches in total, at a mean distance of 22 mm from the proximal end of the incision. A total of 13 lay in the distal half of the incision. For snuff-box incisions, there were 18 vulnerable branches in total, at a mean distance of 11 mm from the proximal end of the incision, with 17 of them lying in the proximal half of the incision. Neither incision is without risk to nerve braches, but our study suggests a lesser risk of subcutaneous nerve damage with the snuff-box approach and highlights the greater risk in the proximal half of this incision.

A cadaveric study of the distribution pattern of the cutaneous sensory fibres of the distal palm of the hand

We investigated the cutaneous innervation of the distal palm, an area frequently dissected by the hand surgeon. Ten (five paired) fresh-frozen cadaveric hands were dissected under 3.0× loupe magnification. Volar branches were found on both sides in the majority of digits. They originated alongside, or at the proximal margin of, the A1 pulley in 84% of digits. The mean distance from the palmar digital crease to the origin of volar branches was 21 mm.

Assessing angulation on digital images of radiographs of fractures of the distal radius: visual estimation versus computer software measurement

We assessed the reliability of visual estimation of angles on computer images of radiographs, and compared their accuracy with the measurement of angles using computer software for ten distal radius fractures. We asked 73 clinicians to visually estimate the dorsal angulation on ten computerized radiographs of fractures of the distal radius. The reliability of these estimations was calculated. Their accuracy was compared to a 'gold standard' obtained by consensus agreement between three consultants measuring these angles using the software. Inter-observer reliability was calculated as ICC = 0.51 and intra-observer reliability as r = 0.76. The visual estimations were less accurate with a mean percentage error of 31% (range, 7-83%). As angulation increased the estimation accuracy improved. Although reliability and accuracy of such estimation was better for clinicians with greater experience, actual measurement was more reliable and accurate.

Review article: tolevamer, a novel toxin-binding polymer: overview of preclinical pharmacology and physicochemical properties

BACKGROUND

Tolevamer is a novel toxin-binding polymer that is currently being investigated in clinical trials for the treatment of patients who have Clostridium difficile-associated diarrhoea.

AIMS

To summarize the results of in vitro and in vivo preclinical studies of tolevamer. In contrast to antibiotics, tolevamer binds C. difficile toxins to interrupt toxin-mediated intestinal inflammation and tissue damage, and does not demonstrate direct antimicrobial activity.

METHODS

Pharmacokinetics/pharmacodynamics were studied in rats and dogs; efficacy was studied in a hamster model.

RESULTS

Studies in rats and dogs indicate that tolevamer is essentially non-absorbed from the gastrointestinal tract and show that drug interactions with commonly used therapies are unlikely. Pharmacologic studies indicate that tolevamer reduces disease severity and recurrence rates in the hamster model of C. difficile-associated diarrhoea and blocks the enterotoxic effects of toxin A in rat ileum. The binding parameters calculated for the interaction of tolevamer with toxins A and B provide a reasonable physicochemical model that supports the potential clinical utility of tolevamer.

CONCLUSIONS

These preclinical results are consistent with the effectiveness and safety profile of tolevamer observed in clinical studies in patients with C. difficile-associated diarrhoea.

Plantar fibromatosis: most common sonographic appearance and variations

PURPOSE

The aim of this study was to describe the most common sonographic appearances of plantar fibromatosis, thus enabling sonographic diagnosis of this benign, focally invasive fibrous neoplasm.

METHODS

The medical records, pathologic reports, and sonographic reports and images of 22 patients with palpable plantar masses were reviewed retrospectively. The sonographic findings were used to characterize those masses with respect to location, shape, size, and echogenicity. Sixteen patients were included in this study because of the proximity of their lesions to the plantar fascia; 6 patients were excluded because their lesions were metatarsophalangeal bursae or ganglia.

RESULTS

The 20 feet examined in the 16 patients studied contained 43 distinct lesions, all located on the surface of the plantar fascia. Thirty-seven (86%) of the 43 were 20 mm long or less. Thirty-seven (86%) of the 43 lesions were elongated; the remaining 6 (14%) were round or oval. Twenty-five (68%) of the 37 elongated lesions had tapered ends, and the other 12 (32%) had rounded ends. Thirty-one (72%) of the 43 lesions were hypoechoic; 25 (81%) of these 31 measured as long as 10 mm. Ten (83%) of the 12 lesions that had mixed echogenicity were longer than 10 mm.

CONCLUSIONS

The lesions of plantar fibromatosis were characteristically located on the surface of the plantar fascia, sagittally elongated, most often less than 20 mm long, fusiform, and hypoechoic. Lesions longer than 10 mm often exhibited mixed echogenicity. The superficial location and appearance should strongly suggest plantar fibromatosis, although careful examination is required to exclude other possibilities, such as sarcoma.

Perinuclear antineutrophilic cytoplasmic antibody-positive cutaneous polyarteritis nodosa associated with minocycline therapy for acne vulgaris

Minocycline is an oral antibiotic widely used for the long-term treatment of acne vulgaris. Unusual side effects of this medication include two overlapping autoimmune syndromes: drug-induced lupus and autoimmune hepatitis. In addition, in a few patients livedo reticularis or subcutaneous nodules have developed in association with arthritis and serum perinuclear antineutrophil cytoplasmic antibodies (P-ANCA) during long-term minocycline therapy. We report the cases of two young women receiving long-term minocycline therapy (>3 years) in whom P-ANCA-positive cutaneous polyarteritis nodosa developed. Both patients presented with a violaceous reticulated pattern on the lower extremities. Histologic examination of biopsy specimens from a reticulated area and a subcutaneous nodule showed necrotizing vasculitis of medium-sized arteries in the deep dermis, consistent with the diagnosis of polyarteritis nodosa. The cutaneous lesions rapidly resolved on discontinuation of minocycline and initiation of prednisone therapy. A high index of suspicion and testing for antineutrophil cytoplasmic antibody in addition to the standard antinuclear antibody panel can facilitate diagnosis of minocycline-related autoimmune disorders.

NF-kappa B inhibition causes spontaneous apoptosis in Epstein-Barr virus-transformed lymphoblastoid cells

Epstein-Barr virus (EBV) transforms B lymphocytes into lymphoblastoid cell lines usurping the Notch and tumor necrosis factor receptor pathways to effect transcription including NF-kappaB activation. To determine whether NF-kappaB activity is essential in the growth and survival of EBV-transformed lymphoblastoid cell lines, a nondegradable IkappaBalpha mutant was expressed under tetracycline regulation. Despite continued Bcl-2 and Bcl-x/L expression, NF-kappaB inhibition induced apoptosis as evidenced by poly(ADP-ribose) polymerase cleavage, nuclear condensation and fragmentation, and hypodiploid DNA content. Both caspase 3 and 8 activation and loss of mitochondrial membrane potential were observed in apoptotic cells. However, caspase inhibition failed to block apoptosis. These experiments indicate that NF-kappaB inhibitors may be useful in the therapy of EBV-induced cellular proliferation.

Epstein-Barr virus-transforming protein latent infection membrane protein 1 activates transcription factor NF-kappaB through a pathway that includes the NF-kappaB-inducing kinase and the IkappaB kinases IKKalpha and IKKbeta

The Epstein-Barr virus oncoprotein latent infection membrane protein 1 (LMP1) is a constitutively aggregated pseudo-tumor necrosis factor receptor (TNFR) that activates transcription factor NF-kappaB through two sites in its C-terminal cytoplasmic domain. One site is similar to activated TNFRII in associating with TNFR-associated factors TRAF1 and TRAF2, and the second site is similar to TNFRI in associating with the TNFRI death domain interacting protein TRADD. TNFRI has been recently shown to activate NF-kappaB through association with TRADD, RIP, and TRAF2; activation of the NF-kappaB-inducing kinase (NIK); activation of the IkappaB alpha kinases (IKKalpha and IKKbeta); and phosphorylation of IkappaB alpha. IkappaB alpha phosphorylation on Ser-32 and Ser-36 is followed by its degradation and NF-kappaB activation. In this report, we show that NF-kappaB activation by LMP1 or by each of its effector sites is mediated by a pathway that includes NIK, IKKalpha, and IKKbeta. Dominant negative mutants of NIK, IKKalpha, or IKKbeta substantially inhibited NF-kappaB activation by LMP1 or by each of its effector sites.

Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player

Worldwide, more people play soccer than any other team sport. The Federation Internationale de Football Association (FIFA) registered more than 150 million players in 1984. Although foot injuries in soccer range from midfoot sprains to stress fractures to capsulitis of the first metatarsophalangeal joint, we could find no case reports of a rupture of the lateral collateral ligaments of the great toe in soccer players. This is a report of the diagnosis, treatment, and outcome of such an injury in a professional soccer player.

How intermediate sanctions change the dynamics of healthcare transactions

The Taxpayer Bill of Rights 2 contains significant reforms relating to tax-exempt organizations, most notably the establishment of intermediate tax sanctions. These changes, which clarify tax rules applicable to tax-exempt HMOs, hospitals, and integrated delivery systems, are of particular interest to entities that are or will be involved in joint ventures or other business alliances with physicians and other for-profit partners, the officers and directors of such entities, and the physicians and for-profit partners in the ventures. For the first time, the legislation imposes monetary penalties on those engaging in transactions with tax-exempt healthcare providers if impermissible private inurement is involved.

Addressing integrated systems' tax-exemption problems

Integrating for-profit providers with charitable providers raises many questions about tax exemption. The traditional criteria for determining tax-exempt status that apply to hospitals do not necessarily apply to integrated delivery systems because of their hybrid nature. The appropriate Internal Revenue Service (IRS) rulings and issues must be understood and adhered to before an integration can be structured in the most tax-efficient way. Reasonable as such a course of action seems, it is somewhat difficult because both the integrated delivery system concept and the IRS rulings that apply are evolving. In a time of flux, this article serves as a timely if temporary guide.

Observations on 200 surgical cases of tarsal tunnel syndrome

Surgical intervention for tarsal tunnel syndrome has been reported since the mid-1960s. In 1975, the authors published their experiences using nerve conduction studies for the diagnosis and follow-up of tarsal tunnel syndrome. Since that time, the authors have operated on approximately 200 cases when conservative care failed to alleviate symptoms to a sufficient degree. In this article, a brief overview of our findings and follow-up is provided.

Atrophia maculosa varioliformis cutis. Report of two cases and review of the literature

Atrophia maculosa varioliformis cutis was initially described in 1918 as an entity in which both linear and punctate scars appeared spontaneously on normal facial skin. To the best of our knowledge, only five additional cases have been described. We describe two patients, 14 and 20 years of age, whose histories and clinical lesions fit the description of atrophia maculosa varioliformis cutis. The histologic findings are also described, and the literature to date is reviewed.

Cardiovascular disease prevention: knowledge and attitudes of graduate nursing students

Graduate nursing students were surveyed to determine the knowledge and attitudes of cardiovascular disease prevention. Questionnaires were self-administered to first-year graduate nursing students (n = 50) in a school of nursing prior to and following a physiology course with cardiovascular disease prevention content. In general, the results demonstrated that the respondents were least knowledgeable regarding the prevalence of smoking, the gender differences in high-density lipoprotein (HDL)-cholesterol levels, the influence of body weight on lipids and the recommended percentages of calories from dietary fat. A significant improvement in knowledge was noted after the course. Positive attitudes regarding the importance of cardiovascular disease prevention and the partnership between patients and clinicians necessary to manage risk were identified. These attitudes did not change significantly following the course. These results indicate that graduate education which emphasizes cardiovascular disease prevention increases knowledge. Coupled with positive attitudes and healthy personal lifestyle behaviours, knowledge of cardiovascular disease prevention may enhance the ability of nurses to integrate preventive standards into clinical practice and ultimately decrease the risk of cardiovascular disease.

Television viewing and pediatric hypercholesterolemia

Cholesterol screening for children is recommended currently only for those with a family history of premature coronary heart disease or hyperlipidemia. The authors report on a pediatric-office-based cholesterol screening program where the predictive values of family history indicators were evaluated along with reported television viewing, physical activity, and dietary habits in 1081 children (aged 2 to 20 years, mean 7.4 +/- 3.6 [SD] years). Eight percent of these children had a total cholesterol value of 200 mg/dL or higher; 53% of such children reported watching 2 or more hours of television daily compared with 34% of children with lower cholesterol levels. Multivariate analyses revealed that excessive television viewing was the strongest predictor for a child to have a cholesterol value of 200 mg/dL or higher, with relative risks of 2.2 for 2 to 4 hours of television viewing per day (P less than .01) and 4.8 for children watching more than 4 hours/day, when compared to those watching less than 2 hours/day (P less than .01). In contrast, a positive family history of a high cholesterol level was only modestly associated with an increased probability of having a high cholesterol level (relative risk = 1.6, P less than .05), and a history of premature myocardial infarction in a parent or grandparent was not associated with a child's cholesterol level. Excessive television viewing was found to be associated with certain dietary and physical activity habits and may prove to be a useful, global marker for several life-style factors predisposing children to hypercholesterolemia.

Cholesterol screening in children during office visits

Elevated blood cholesterol levels, a major risk for coronary artery disease in adults, has been associated with atherosclerotic disease in children. More than 10% of North American children have blood cholesterol levels higher than the desirable levels for adults. Current guidelines recommend screening only in children who have a family history of hyperlipidemia or myocardial infarction at an early age; however, this method fails to identify most children with hypercholesterolemia. Office-based cholesterol screening is an effective means to identify children and family members for dietary assessment and counseling. Should these measures be insufficient to lower the child's cholesterol level, referral for pharmacologic treatment is indicated.

Teaching preventive cardiology through community programs

Entering medical students currently report positive attitudes toward the concept of preventive cardiology but express a lack of confidence in the physician's ability to change unhealthful habits of their patients. One approach to this problem has been the involvement of medical students and house staff physicians in cardiovascular health programs offered in the community. With the goal of enhancing the knowledge, attitudes, and skills of the trainees, these programs have been carried out in educational institutions at all levels, in churches, and at work sites, shopping malls, and health fairs. Informal assessment of these programs suggests that medical trainees develop an increased sense of confidence in their ability to influence positively the health habits of children and adults.

Risk factors for cardiovascular disease in U.S. medical students: the Preventive Cardiology Academic Award Collaborative Data Project

Risk factors for cardiovascular disease are commonly obtained in freshman medical students for the purpose of increasing interest and awareness in preventive cardiology. What would be a normal range of values for this select group? This paper describes the major cardiovascular risk factors for 3,811 male and female freshman medical students from eight U.S. medical schools that were obtained in a standardized fashion as part of the Preventive Cardiology Academic Award (PCAA) programs at these institutions. The distributions of height, weight, Quetelet index, systolic and diastolic blood pressures, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and calculated low-density lipoprotein cholesterol are presented for male and female medical students stratified by race into white, black, Asian, and Hispanic groups. The sex and race distributions of cardiovascular risk factors such as previously diagnosed hypertension, diabetes mellitus, smoking, lack of regular exercise (three times a week or more), oral contraceptive use in women, and family history of coronary heart disease are presented. The cardiovascular risk of freshman medical students is compared to other epidemiologic studies of young adults. The use and limitations of these race- and sex-specific data on cardiovascular risk, including physiologic measurements, are discussed in the context of educational programs for medical students and house staff in preventive cardiology.

Effects of short-term exposure to carbon monoxide in subjects with coronary artery disease

Twenty-four male subjects with stable angina pectoris performed graded exercise tests after being exposed to either carbon monoxide (CO) or clean air in a randomized crossover double-blind experiment in which each subject acted as his own control. Subject's blood carboxyhemoglobin levels were increased from a baseline level of approximately 1.5% to 3% of saturation, post-CO exposure. Cardiographic and respiratory gas exchange data were obtained during the tests in which the subjects exercised to the point of onset of anginal pain. The goal of the study was to determine if low-level CO exposure compromised the ability of these individuals to perform work. Data were evaluated statistically using a two-factor analysis of variance with repeated measures; the factors were exposure ATMOSPHERE (clean air vs. CO) and ORDER of exposure (clean air first, CO second vs. CO first, clean air second). One-tailed tests were used, and differences were considered significant at the p less than .05 level. The time to onset of angina was reduced 6% (p = .046) after CO exposure relative to clean air. Oxygen uptake (VO2) at angina was reduced by approximately 3% (p = .04). A subgroup of individuals who exhibited depression in the ST segment of their electrocardiograph tracings showed a 12% reduction in time to onset of angina and a 20% reduction in the time to onset of 0.1 mV ST segment depression; both of these findings were also statistically significant.

Cardiovascular effects of alcohol

The effects of alcohol on the heart include modification of the risk of coronary artery disease, the development of alcoholic cardiomyopathy, exacerbation of conduction disorders, atrial and ventricular dysrhythmias, and an increased risk of hypertension, hemorrhagic stroke, infectious endocarditis, and fetal heart abnormalities.

School-based blood cholesterol screening

Coronary artery disease, the major cause of death in developed countries, begins early in childhood. Elevated blood cholesterol, a major risk for coronary artery disease in adults, has been associated at autopsy with atherosclerotic disease in children. To explore the feasibility of mass screening of blood cholesterol levels in children, a school-based screening and education program for fourth-graders was carried out in a Southern California school district. Approximately 10% of the children had blood cholesterol levels of 200 mg/dl or more, the upper limit of desirable levels for adults. These children and their parents returned for repeat cholesterol testing and nutrition counseling. A family history of early coronary artery disease was present in only one third of the children with high cholesterol levels; this fact, coupled with consumable costs less than $2 per child, suggests that cholesterol screening is a practical, cost-effective addition to school health programs.

Attitudes toward prevention of cardiovascular diseases among first-year students at eight American medical schools, 1983-1985

First-year medical students at eight U.S. medical schools were surveyed by written questionnaire in 1983-1985 to determine their attitudes toward cardiovascular diseases prevention at medical school entry. An overall response rate of 92% was achieved (2,654 questionnaires), and 97% of responders provided complete and analyzable survey data. Response rates at five of eight medical schools were 98-100%, and one school each had rates of 67, 84, or 90%. Differences in mean attitude responses from school to school were small, as were differences between men and women or between blacks and whites. This survey found that entering medical students have generally positive attitudes toward the effectiveness of preventive cardiology practice as well as toward the importance of research efforts in cardiovascular disease prevention. Students frequently indicated, however, that it is "extremely difficult" to change patients' unhealthful habits and that "physician encouragement" may not be sufficient to help patients achieve more healthful behaviors. These findings could be helpful in directing educational efforts for medical students. The data suggest that major emphasis should be placed on conveying facts regarding the physicians' efficacy in clinical preventive cardiology and on teaching the skills of preventive cardiology practice. Less emphasis appears to be necessary on encouraging positive attitudes about the importance of prevention since current students' attitudes appear to be already positive in this dimension.

Oat bran as a cholesterol-reducing dietary adjunct in a young, healthy population

In a study to examine the effects of dietary oat bran on serum lipids, subjects who ate two oat bran muffins a day for 28 days showed a 5.3% reduction in serum total cholesterol and an 8.7% reduction in low-density-lipoprotein-cholesterol levels, while no changes were noted in subjects consuming wheat or mixed wheat and oat bran muffins. Similarly, those who ingested oat bran muffins showed an 8.3% reduction in serum triglyceride values as contrasted with an overall increase of 6.4% in the other groups combined. These findings suggest that oat bran taken daily can significantly lower serum cholesterol and triglyceride levels in a young, healthy population.

Skeletal muscle profiles in elite springboard and platform divers

This investigation determined the vastus lateralis muscle fiber composition, as well as leg power and strength, in a group of 10 world class divers. Male divers had a low mean percentage of Type I fibers (36%), which was consistent with the functional demands of their sport, whereas females had a mean value of 61%. The ratio of Type I/Type II cross-sectional fiber area was 0.95 in females and 0.82 in males. Angle-specific torque-velocity relationships, derived from Cybex testing of the knee extensors, revealed high torque values in males but not in females. The observed male-female differences have no clear explanation, unless muscle fiber composition has greater importance in the more difficult dives executed by men.

Relationship between age, body size, gender, and blood pressure and Doppler flow measurements in the aorta and pulmonary artery

Previous studies have demonstrated a relationship between both age and body surface area (BSA) and M-mode echocardiographic measurements of left ventricular, left atrial, and aortic root dimensions and left ventricular wall thickness. We evaluated the relationships between age, BSA, gender and blood pressure, and Doppler aortic and pulmonary artery (PA) flow velocity measurements in 97 adults, aged 21 to 78 years, without clinical evidence of cardiac disease. No significant relationship was found between gender or blood pressure and aortic or PA flow velocity measurements. Aortic peak flow velocity, flow velocity integral, and average acceleration decreased with increasing age (all p less than 0.001), whereas ejection time (corrected for heart rate) increased, and acceleration time did not change. In contrast, there was no relationship between age and Doppler PA flow velocity measurements. Although there was no relationship between BSA and Doppler aortic flow measurements, PA peak flow velocity and average acceleration increased, while acceleration time decreased with increasing BSA (all p less than 0.02). Decreases in aortic peak flow velocity and flow velocity integral may be partly related to known increases in aortic root diameter with aging. The relationship between PA flow velocity measurements and BSA is not readily explained.

Defective gamma-interferon production in peripheral blood leukocytes of patients with acute tuberculosis

Production of interferon (IFN)-gamma by peripheral blood leukocytes (PBL) was examined in cultures of unseparated fresh whole blood exposed to phytohemagglutinin (PHA), concanavalin A (Con A), or pokeweed mitogen (PWM). The yield of IFN-gamma was measured by a newly developed immunoradiometric assay. Nine of 14 patients with acute pulmonary tuberculosis (TB) showed a depressed IFN-gamma response to Con A and/or PWM. Only four of these TB patients also showed a depressed IFN-gamma response to PHA. Stimulation of the patients' PBL cultures with PHA in the presence of exogenous interleukin 2 (IL 2) produced normal IFN-gamma yields in all but the most severely depressed patients. PBL cultures of TB patients with defective IFN-gamma production in response to mitogenic lectins also produced less IFN-gamma after stimulation with tuberculin PPD. Although some patients showed a moderate degree of lymphopenia, their OKT4/T8 lymphocyte ratios were mostly normal or close to normal, with the notable exception of one TB patient who has been diagnosed to have the acquired immune deficiency syndrome (AIDS).

Skeletal muscle profiles among elite long, middle, and short distance swimmers

Skeletal muscle profiles of fiber composition and leg power and strength were obtained in 30 national caliber swimmers (20 males, 10 females). Subjects were classified into three groups based upon the distance of their primary events [long distance (LDS), middle distance (MDS), and short distance (SDS) swimmers]. Intergroup analyses showed that the LDS group had the highest values of percent Type I muscle fiber composition (percent Type I and percent Type I area), and the lowest values of leg power and strength values (vertical jump and torque-velocity relationships). In addition, when grouped by Type I fiber composition, subjects having greater than or equal to 50% Type I fibers had significantly lower vertical jump and torque values than those having less than 50% Type I fibers. Overall, the compositional and functional measurements were consistent with the specific metabolic and contractile demands of the different swim groups.

Recovery after cardiac events

This article describes an interdisciplinary program of cardiac rehabilitation that integrates physical therapy with medical, nursing, nutritional, and psychological assessment and treatment. Hospitalized patients recovering from myocardial infarction or cardiac surgery progress through a seven-level program of physical activity, education, and emotional support. These components of the program continue during their early home period and again are integrated during the active training period. In the active training period, patients participate in support groups and receive nutritional, exercise, and medical education and engage in one hour of exercise three times weekly. In all phases, considerable attention is given to the development of behavioral skills necessary for long-term adherence to healthy life style habits.

Family-directed preventive cardiology

Cardiovascular events continue as the leading cause of death in the United States, despite a decline in recent years. Epidemiological evidence has confirmed that in adults smoking, high blood pressure, hypercholesterolemia, a family history of atherosclerotic disease at an early age, diabetes mellitus, and certain behavioral patterns are associated with a higher risk for myocardial infarction and other manifestations of coronary artery occlusion. In addition, a lack of regular physical activity, being overweight, and excess ethanol consumption are associated with increased cardiac disease rates. Since these indicators of risk may appear in childhood, and the earliest manifestations of atherosclerosis or hypertension can become manifest soon thereafter, the prevention of cardiovascular events must begin early. This paper reviews the evidence for the origins of cardiovascular risk in childhood, and offers recommendations to family physicians to help them provide parents with the proper information, motivation, and skills to teach their children healthy nutritional, exercise, and behavioral patterns.

Propionibacterium shunt nephritis in two adolescents with medulloblastoma

The anaerobic diphtheroid Propionibacterium acnes was identified as the organism responsible for "shunt" nephritis in two adolescents with ventriculoatrial shunts inserted previously for the management of medulloblastoma. Only three cases of "shunt" nephritis secondary to infection with this common skin commensal organism are known to have been reported. The rarity of such reports may be related to the lack of good anaerobic laboratories, the length of time necessary for cultures to show growth, the poor ability of certain blood culture media to support growth of this organism, and the failure of physicians to consider Propionibacterium acnes as a true pathogen in certain clinical situations.

Autonomic contribution to heart rate recovery from exercise in humans

To assess the contribution of the autonomic nervous system to heart rate recovery following exertion, heart rate was observed after peak treadmill exercise in six men following parasympathetic blockade (PB) with atropine sulfate (0.03 mg/kg), sympathetic blockade (SB) with propranolol hydrochloride (0.20 mg/kg), double blockade (DB) with both drugs, and no drugs (ND). Least-squares analysis of each subject's heart rate (HR) as an exponential function of recovery time (t) was computed for each treatment giving an equation of the form HR = aebt. HRs at rest, peak exercise, and 10 min of recovery, the coefficients a and b, and the least-squares correlation coefficient (r) were compared among treatments by nonparametric analysis of variance and rank-sum multiple comparisons. HR recovered in an exponential manner after dynamic exercise in each subject with each of the treatment modes (P less than 0.01 for each r, mean across all treatments r = 0.94). Coefficients a and b differed the most between PB and SB. At the cessation of exercise the decreases in venous return and the systemic need for cardiac output are accompanied by an exponential HR decline. The exponential character of the cardiodeceleration seen after peak exercise appears to be an intrinsic property of the circulation because it occurred under each experimental condition.

The effect of a standardized psychological stressor on the cardiovascular response to physical effort soon after uncomplicated myocardial infarction

To determine whether a standardized psychological stressor combined with physical stress might disclose ischemic abnormalities not evident with physical stress alone, 30 men, mean age 54, were evaluated seven weeks after clinically uncomplicated myocardial infarction. In the first 20 patients, two symptom-limited treadmill tests (TM) were performed on the same day, with and without superimposed psychological quiz (Q). In the next 10 consecutive patients, the Q was administered at a submaximal level (4 METs). When TM and TM + Q responses were compared, no significant differences were noted in the maximal levels of heart rate (HR), systolic blood pressure (SBP), rate pressure product, or in the prevalence of ischemic ST segment depression or angina pectoris. The HR and double product at which ischemic ST segment depression and angina pectoris appeared were similar for the two types of testing. The psychological stress of a psychological quiz may not, of course, approximate the effect of the more severe stressors individuals may encounter in their daily routines.

The work evaluation of the cardiac patient

Treadmill exercise testing performed three weeks following clinically uncomplicated myocardial infarction was used to assess the occupational work potential of 196 men aged 70 or less. Within the six months after infarction the rate of combined medical and surgical events (sudden death, nonfatal cardiac arrest, myocardial infarction or coronary artery bypass graft surgery) was 34% in the one-quarter of patients judged to be at high risk and 4% in the three-quarters of patients judged to be at low risk on the basis of exercise testing--an eight-fold difference. Seven weeks or more after infarction, treadmill testing or leg-cranking ergometry proved more sensitive than static effort or arm cranking or treadmill exercise combined with static effort in the detection of ischemic and arrhythmic abnormalities. Occupational work assessment may limit costs for postinfarction patients in two ways: (1) by facilitating optimal usage of diagnostic tests and therapeutic interventions in high-risk patients; and (2) by obviating needless delay in the return to work of low-risk patients.

Atypical erythema multiforme--a marker of malignancy? Report of a case occurring with renal cell carcinoma

A patient who presented with clinically atypical erythema multiforme was found, on investigation, to have an occult renal cell carcinoma. The skin eruption did not respond to systemic steroids, but resolved completely when the tumor was excised. Atypical erythema multiforme in a patient warrants a search for underlying malignancy.