Influence of primary tumor site on host anti-tumor immunity.

Stage IV-S neuroblastoma, characterized by a primary tumor plus disseminated tumors in liver, skin and bone marrow, has a favorable clinical prognosis when compared to metastatic Stage IV neuroblastoma. This favorable outcome also characterized mice receiving tumor transplants to these "IV-S" sites. We report the testing of the hypothesis that enhanced anti-tumor immunity in "IV-S" site neuroblastoma recipients explains this improved survival. A million murine C1300 neuroblastoma cells were inoculated into 256 A/J mice to either "IV-S" sites of skin, liver, peritoneal cavity, or to the disseminated stage "IV" sites of subcutaneous tissue, muscle, kidney and lung. After 21 and 28 days of tumor growth, spleen cells from tumor bearing mice were harvested and analyzed by a 51 Cr release lymphocytotoxicity assay. Cytotoxic T cell activity was consistently higher at day 28 than day 21. In the liver and in the peritoneal cavity, cytotoxic T cell activity was higher than in other organs, and at day 28 these values were significantly higher than Stage "IV" sites. On the other hand, skin is not a immunologically privileged site in vivo study.


Partial mastectomy with axillary lymph node dissection and radiotherapy as a new treatment modality of breast cancer (I).

This is the first preliminary report among two consecutive papers. Partial mastectomy(PM), axillary lymph node dissection(AD) and radiotherapy (RT) were performed on seventeen operable breast cancer patients who had been admitted from April 1991 to March 1992 to the department of surgery, Yongdong Severance Hospital for improved cosmetic appearance and better survival rate. Of seventeen patients, 47% were T1 lesion and 76% were stage I and II. Extensive intraductal component(EIC) within or around the tumor was also analyzed. Twenty nine per cent of the patients were EIC positive. The mean number of axillary lymph nodes was 21.5 after PM with AD and 20.5 after mastectomy. For radiotherapy, 4,500 rad was delivered to the breast parenchyma and 1,600 rad of boost to the primary tumor site using the electron beam method after surgery. All patients have since been living well without any local recurrence and were satisfied with breast preservation for the one-year follow-up period. We concluded that the PM, AD and RT can be another surgical treatment modality of breast cancer. A longer follow-up data will be followed on the second paper.


Multiple basal cell carcinoma associated with keratoacanthoma.

We report a case of multiple basal cell carcinoma associated with keratoacanthoma. A 65-year-old Korean female had suffered from multiple, variable-sized papules and nodules on the face for 20 years previous to treatment. She had no history of arsenic intake, irradiation, herb medication, or hereditable or preexisting dermatoses. Histopathologically, the tumors revealed typical findings of solid and adenoid types of basal cell carcinoma and keratoacanthoma.


A case of anaphylaxis by ant (Ectomomyrmex spp.) venom and measurements of specific IgE and IgG subclasses.

Hypersensitivity to the stings of the Hymenoptera has been described since antiquity. The hypersensitive reactions to insect stings vary from minor skin reactions to severe and sometimes fatal anaphylaxis. Concerns about sting hypersensitivity have been increasing because of many incidents of allergic reactions of patients to the fire ant in the southern area of the United States as well as the harvester ant in some areas. We experienced one unique case with severe allergic reactions by ant of the Ectomomyrmex spp. of the subfamily Ponerinae, which is not a harvester ant. For three years the patient had been suffering from generalized allergic reactions such as anaphylaxis after the ant stings four-five attacks in a year. We determined that her reactions were due to specific IgE mediated type I hypersensitivity by the detection of a high level of specific IgE to the ant venom in her serum. The high level of specific IgG4 to the ant venom was also noted in her serum, however, the role of ant venom IgG4 was not clearly determined.


Simultaneous repair and rebase of a removable partial denture.

A patient presented a unique dental problem: the evulsion of mandibular canines, and the restoration of anterior alveolar bone associated with periodontal disease. A mandibular removable partial denture, bilaterally supported by the canines, premolars, and molar abutments of blade implants, had been worn for more than ten years. The open clasps in the canine areas were irritating the oral tissues, and the space under the anterior saddle of the denture was retaining food. Both situations needed immediate consideration. The evulsed canines were reproduced in autocured acrylic and secured in the clasps of the denture. The space under the saddle was rebased with autocured acrylic. Since both areas were adjacent to each other, they were splinted together simultaneously. The patient was satisfied with having the old denture repaired without being deprived of the prosthesis for an extended period of time.


Classification and coding in neurosurgery.

Twelve years' experience in classification and coding by a neurosurgical department serving a population of about 1.5 million is presented. The involvement of clinicians and the relationship to health service resource management is demonstrated. The incorporation of a comprehensive coding system (the READ codes) is outlined.


[The cytoarchitectonics of the adenohypophysis in light of the concepts of cellular flows].

Analysis of published data allows to suggest a possible model of adenohypophyseal cytoarchitectonics based on the concepts of tissue self-renewal and streaming in this gland. The model provides a framework for understanding: a) the existence of ambiguous cellular elements; b) change of relationship between different types of hormone secreting cells with sex-dependent prevalence of somato- or lactotrophs; c) relatively high proliferative activity of lactotrophs in mature pituitary gland; d) specific spatial arrangement of various types of hormone secreting cells; e) multiple effects of some bioregulators on the secretion of two or more pituitary hormones; f) the existence of polyfunctional pituitary adenomata containing and secreting several adenohypophyseal hormones simultaneously. Possible approaches to thorough evaluation and testing of the model in experiments using organ or cell cultures of adenohypophysis are discussed.


[Quality assurance--an important factor in the structure of medical management of the future].

Quality of medical practice has several prerequisites. A certain structural quality is essential to ensure good quality medical performance. Structural and performance quality both lead to result quality. Performance quality is dependent on well-working structures. With respect to neurosurgery a high level hospital organisation is required which allows equally qualified medical performance. Structure therefore has to attain a standard to stand up to quality assurance criteria. Next to hospital equipment structural quality requires sufficient staff capacity as well as unlimited neurosurgical access to technical equipment such as computerized tomography, MR, angiography and also intensive care under neurosurgical supervision. Quality assurance has been widely discussed in recent years. Measures to guarantee quality assurance, as required by federal law in Germany, are taking three different steps, first a model phase as a scientific study developing methods and observation, a second phase called study phase with wide effects and institution in various departments. In this phase the effectiveness of the procedure is tested and assured. In the third phase routine use is instituted. In quality assurance in neurosurgery phase two is presently tested, phase three is in preparation.


[Evaluation of economic business management in the hospital. Results from four neurosurgical clinics].

An audit of economicalness performed by one company from 1980 to 1985 in four neurosurgical departments is presented. The report is restricted to medical care. There is a considerable difference in findings: in the department first looked at there are 3.8 patients per surgeon and in the 1985 examination 5.4. These departments being well comparable otherwise both judgement and competence of the business consultants involved must be questioned.


Alpha thalassaemia in Saudis.

The alpha-thalassaemias are group of inherited anaemias. Their severity is known to increase with the number of alpha-globin genes deleted. Employing different types of restriction enzymes, we found that alpha-thalassaemia-2 are more common than held previously. On the basis of our results we also anticipate that the haplotype alpha alpha alpha anti3.7/ occurs at a higher frequency.


Hydroxyurea for the treatment of sickle cell disease.

In this study 21 adults with severe form of sickle cell disease (SCD; sickle cell anaemia, n = 15; Hb S/beta degree-thal, n = 6) were treated with hydroxyurea (HU) to assess the effectiveness of the drug in managing SCD. The individual dose was selected for each patient. The dose selection was based on the HU clearance study. Thereafter, the patients received daily doses of 15-20 mg/kg body weight. An evaluation data form was filled out at the monthly visit. The severity index (SI) of the disease was determined and haematological parameters including red cell indices, platelet counts, reticulocyte counts, irreversibly sickled cells, red cell deformability, Hb F, Hb F cells, total and direct bilirubin levels were measured prior to treatment, at follow-up intervals during treatment and after cessation of treatment. The trial period lasted 3 months. Statistically significant improvement was observed in the clinical presentation, haematological and biochemical parameters. Hb F level and F cells showed a significant increase in most patients, but to a variable degree. A major resultant effect was an increase in mean cell volume. Our experience shows that HU can be used for the treatment of severe forms of SCD with no major side effects, provided that the doses are monitored and that laboratory investigations are regularly undertaken.


Neutralization and immunoaffinity chromatography of erythroid colony-stimulating activity in mouse plasma by an anti-erythropoietin monoclonal antibody.

A relationship between erythropoietin (EPO) and erythroid colony-stimulating activity (ECSA) in mouse plasma was examined in fetal mouse liver cell (FMLC) cultures using a monoclonal antibody (MoAb) R2 raised against recombinant human EPO. Most of the ECSA in plasma from normal, anemic, and hypoxic mice was neutralized by MoAb. This neutralization could be reversed by addition of excess of anemic plasma or by preincubation of MoAb with goat anti-mouse IgG antibody. Most of the plasma ECSA was bound to an immunoadsorbent column containing the immobilized MoAb, and the retained ECSA was completely neutralized by MoAb. The plasma ECSA and standard EPO showed parallel dose-response curves and additive effect on CFU-E stimulation. Based on these findings, we conclude that mouse plasma ECSA detected by CFU-E assay using FMLCs is mainly due to EPO.


Serum selenium status in children with iron deficiency anemia.

Serum selenium concentration was investigated in 40 children with iron deficiency anemia and in 40 control subjects matched for age, sex and geographical origin. A spectrofluorometric method was used for determination of the selenium level. It was found to be significantly lower (p < 0.001) in the patient group, which consisted of both normally developed and malnourished children. Patients also having pica had higher levels of selenium compared to patients without pica. There was no relation between the serum selenium concentration and hematological parameters such as hemoglobin, serum iron, serum iron binding capacity and unsaturated iron binding capacity. However the results of 15 patients followed during iron therapy indicated that the duration of the anemic period may affect the selenium concentration. This study also suggests the effectiveness of iron and selenium administration.


Severe congenital dysfibrinogenemia (fibrinogen-Riyadh): a family study.

Congenital severe dysfibrinogenemia was discovered in a small Saudi family. Their single child exhibited abnormal severe bleeding tendency since birth and his coagulation profile revealed evidence of severe dysfibrinogenemia. The parents who were first-degree cousins and completely asymptomatic showed evidence of dysfibrinogenemia but to lesser degree than in their son. The child presented with large cephalohematoma and evidence of intracranial hemorrhage and left hemiparesis. He was treated with cryoprecipitate and his hematoma resolved, but his neurological deficit remained.


Long-term survival of a baby with homozygous alpha-thalassemia-1.

Triplets born to a Chinese woman consisted of 2 healthy boys and a girl with hemoglobin Bart's hydrops syndrome. The girl with hemoglobin Bart's hydrops syndrome, confirmed by gene analysis to be homozygous for alpha-thalassemia-1, survives for 27 months at the time of reporting. The dilemma in sustaining her life and the availability of other therapeutic options are briefly discussed. This is the third case report of homozygous alpha-thalassemia-1 with long-term survival.


Cytogenetic evidence for extramedullary blast crisis with t(8;13)(q11;p11) in chronic myelomonocytic leukemia.

A 27-year-old male developed massive generalized lymphadenopathy with chronic myelomonocytic leukemia (CMML) presenting as extramedullary blast crisis mimicking a lymphocytic lymphoma. On presentation, a consistent chromosomal abnormality involving chromosomes 8 and 13, i.e. 46,XY,t(8;13) (q11;p11), was present in lymph node tissue, bone marrow and unstimulated peripheral blood. The appearance of trisomy 21 in addition to the presence of the original cytogenetic abnormality is simply regarded as clonal evolution, i.e. 47,XY,t(8;13)(q11;p11),+21. The importance of the cytogenetics lies in finding the same abnormality in bone marrow and lymph node, adding evidence that the immunologically similar cells in the two sites have arisen from a common progenitor cell. To our knowledge, this novel chromosomal abnormality has not been reported in association with a unique case.


Isolated cerebellar infarction as a presenting symptom of polycythemia vera.

Although polycythemia vera is one of the reported causes for cerebral infarction, isolated cerebellar infarction, a rare disorder, was never reported in combination with polycythemia vera. This is a report of a 72-year-old woman in whom isolated cerebellar infarction was the presenting manifestation of polycythemia vera. The patient was treated with recurrent phlebotomies until the hematocrit decreased to < 45%. This treatment was followed by marked neurological improvement. A better awareness of the possibility of cerebellar infarction in polycythemia vera may disclose additional cases.


Adult T cell leukemia associated with eosinophilia: analysis of eosinophil-stimulating factors produced by leukemic cells.

The mechanism of eosinophilia in a patient with adult T cell leukemia (ATL) was investigated. A 61-year-old woman with ATL presented marked eosinophilia. No parasite infections or allergic diseases were found in this patient. The number of eosinophils fluctuated in parallel with that of ATL cells during her clinical course. The patient's serum and the culture supernatant of ATL cells showed eosinophil colony-stimulating activity. Northern blot analysis of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-3 (IL-3), and interleukin-5 (IL-5), which are known eosinophil CSFs, showed that only GM-CSF but not IL-3 or IL-5 was expressed in freshly separated and cultured ATL cells. Since neutrophil and monocyte numbers did not increase, it is suggested that GM-CSF and unknown cytokines other than IL-3 and IL-5 produced by ATL cells synergistically stimulated eosinophil precursors in the present case.


Factors which predict performance on the National Certification Examination for Nurse Anesthetists.

Predicting the performance of registered nurse anesthesia students (RNAS) on the national certification examination (NCE) is an area of interest to educators, students, and employers. Following graduation from an accredited nurse anesthesia educational program, RNAS must pass the NCE to practice. The purpose of this study was to investigate 13 academic, demographic, and preadmission factors which predict RNAS' performance on the NCE. This retrospective analysis included 1,690 RNAS who took the five NCEs administered from December 1987 through December 1989. Results of multiple regression analyses revealed that seven of the 13 academic, demographic, and preadmission variables were predictive of performance on the NCE. These variables included science and overall grade point average (GPA), highest degree attained before entry, gender, number of cases, age, and years of nursing experience. The GPA in science accounted for 24% of the variance in the overall certification examination score, and the remaining six variables contributed an additional 3% to the variance. Variables which were not predictive of performance on the NCE included type of nursing preparation, clinical background, type of nurse anesthesia program, case hours, number of science hours, and length of the nurse anesthesia program. Additional research findings from the one-way analysis of variance of the categorical variables indicate that level of education before entry into a nurse anesthesia educational program is predictive of performance on the NCE. RNAS with bachelor's or master's degrees achieve higher mean certification examination scores than RNAS with diplomas or associate degrees. Similar results were found for the type of nurse anesthesia program.(ABSTRACT TRUNCATED AT 250 WORDS)


Hearing loss after general anesthesia for cecectomy and small bowel resection.

Acute hearing deficit following nonotologic surgery and general anesthesia is a rare phenomenon. Hearing loss following anesthesia has more commonly been associated with spinal anesthesia or following cardiopulmonary bypass surgical procedures. This case study describes a patient who developed a left-sided hearing loss after cecectomy and small bowel resection. The postoperative management was directed toward reversing idiopathic hearing loss secondary to a microvascular hypoperfusion etiology. Possible causative factors and the management of sensorineural hearing loss following anesthesia are discussed.


Effective methods of in-line intravenous fluid warming at low to moderate infusion rates.

Three methods of warming intravenous (IV) fluids were examined. An in-line blood warmer was generally ineffective at flow rates of < 250 mL/hr but did produce temperatures of 30 to 31 degrees C at the catheter when the infusion rate was 500 to 1,000 mL/hr and the tubing was insulated. An in-line hot water bath produced temperatures of > or = 30 degrees C at flow rates of 200 to 1,000 mL/hr with uninsulated tubing. The addition of insulation maintained on infusate temperature of > or = 30 degrees C at a rate of 100 mL/hr. Application of a K-Thermia pad to the IV tubing close to the patient maintained an infusate temperature of > or = 30 degrees C at rates of 50 to 200 mL/hr. Warming at rates of 200 to 1,000 mL/hr is most effective with an in-line hot water bath. Warming at low infusion rates is best accomplished with a K-Thermia pad. The use of in-line blood warmers for routine fluid warming is ineffective.


AANA journal course: update for nurse anesthetists--blood-brain barrier function alteration during anesthesia.

With some exceptions, the entire central nervous system (CNS) is encircled by the blood-brain barrier (BBB). The function of the BBB is to sustain the CNS in a homeostatic environment. A variety of occurrences during an anesthetic have been shown to disrupt the BBB. Alterations of electrolytes or drugs in the systemic circulation at the time of a disruption in the BBB could result in an abnormal concentration of these molecules in the CNS leading to abnormal CNS neuronal transmissions which may manifest as both intraoperative or postoperative problems.


Assessment of a self-designed protocol on patients with adverse reactions to beta-lactam antibiotics.

Suspected adverse reactions to beta-lactam antibiotics are the most frequent reason for consultation in relation WMH drug allergy. Because of their therapeutical usefulness and wide use, we developed a protocol for confirmation or exclusion of this type of allergy. The proposed protocol is based on clinical, causal and laboratory criteria that are used to assign scores from 0 to 9 points. Patients with scores between 0 and 3 are considered to be highly prone to beta-lactam antibiotic allergy and are given an alternative therapy that is selected by applying skin provocation tests (SPT). Those with a score of 9 points are excluded. Finally, those with scores between 4 and 8 are subjected to skin tests with 5 antigens (penicillin G, ampicillin, cephalothin, Penkit PPL and Penkit MDM); if they give negative results they are subsequently subjected to oral provocation with beta-lactam antibiotics. In this work we report the results obtained from 150 patients analysed for 28 variables altogether. The results allowed us to rule out adverse reactions in 94 patients. Only 9 individuals yielded positive skin tests, and only one gave a positive oral provocation (bronchospasm, 6 hours after subjection to the test). The usefulness of the proposed protocol, the profitability of the test applied and the mechanisms involved are assessed.


A multi-allergen ELISA screening method. Comparison with Pharmacia CAP system and Phazet skin prick test.

Eighty consecutive subjects, coming to our service as suffering from conjunctivitis and/or rhinitis and/or asthma, were investigated by a new multi-allergen enzymatic screening immunoassay (Profilo, Bio-Allergy, Rome, Italy) regarding to serum specific IgE for groups of inhalant allergens (Dermatophagoides, Parietaria, grasses, trees, animal danders). These groups include allergens which are most frequently responsible of allergy in our country. Indices of diagnostic accuracy of this assay were analyzed in relation to skin prick test (SPT, Phazet, Pharmacia), as in vivo reference test, and Pharmacia CAP System, as in vitro reference test, comparing the results achieved by these tests in the same group of subjects. Profilo showed high significant (p < 0.0005) correlations and satisfactory indices of diagnostic accuracy (sensitivity, specificity, predictive values of positive and negative, and efficiency) for the tested allergens with reference to both Phazet SPT and CAP System. In addition, the method appeared very rapid and simple, so that it could be performed in the physician's office.


Comparison between late onset and childhood asthma.

The onset of asthma frequently occurs after the age of 50 yr and the severity and causes of this late onset disease are poorly known. 25 chronic asthmatics (65.7 +/- 6.5 yr) whose asthma started after the age of 50 yr were compared with 23 chronic asthmatic children (11.6 +/- 2.8 yr) and 24 COPD patients (61.6 +/- 3.4 yr). Both asthmatic groups had a similar apparent duration of asthma. None of the asthmatics was a smoker. All COPD were smokers. The severity of asthma was defined according to the Aas score. FVC, FEV1, MMEFR, Raw were tested and reversibility of bronchial obstruction was determined on Raw after salbutamol inhalation. Allergy was assessed by skin prick tests, RAST and total serum IgE (PRIST). Patients with childhood asthma had: 1) a significantly lower clinical severity of asthma; 2) a significantly less severe bronchial obstruction, and 3) a significantly greater reversibility than old age asthmatics. There was no significant difference between pulmonary function tests pre- and post-bronchodilators between COPD and old-age asthmatics. All asthmatic children and 40% of older patients were allergic. The occurrence of asthma in old age patients leads to a more severe course of the disease and allergy appears to play a role in many old age patients.


Allergic skin reactivity in 232 patients over 50 years.

We examined two hundred and thirty-two out-patients, ranging in age from 50 to 75 yrs. All patients were submitted to skin-tests: prick and, if it was necessary, intradermal reactions and/or RAST. Allergens employed were Gramineae, Parietaria, Olea, dermatophagoides Farinae, dermatophagoides Pteronyssinus, house dust, cat and dog skin scales. One hundred and twenty-eight subjects had positive responses to one or more aeroallergens. Asthma was the most frequent condition both in skin-positives and in skin-negatives. For 58% of skin-positives and 51% of skin-negatives the symptoms' onset was more than 10 yrs before our check. In 58.6% of patients we found positive reaction to dermatophagoides Farinae, in 51.5% to house dust, in 47.6% to dermatophagoides Pteronyssinus, in 34.3% to Gramineae, in 28.9% to parietaria and in 14.8% to olea. Fifty-four skin-positives subjects carried out lung function tests; in twenty-eight of them we found a bronchial obstruction. In more than 50% of the subjects, which had shown a reactivity to aeroallergens, we prescribed a specific hyposensitization. These data suggest that skin tests results in elderly patients can have a relevant role in preventive and pharmacological treatment, improving life quality.


Determination of eosinophil rate after nasal provocation test in allergic rhinitis diagnosis.

After nasal provocation test in patients with allergic rhinitis, using the allergen they were sensitized to, we have observed: 1) an increase in the percentage of nasal eosinophils after 2, 3, 24 and 48 hours; 2) sneezes, mainly in the first 30 minutes; 3) nasal obstruction in the first three hours; 4) absence of rhinorrhea, but not in all the patients; and 5) no predominance of nasal, auricular and/or palatine pruritus at any time. When patients without rhinitis, or with allergic rhinitis were stimulated using a pneumoallergen they were not sensitized to, no significative increase in the nasal eosinophils percentage was found. No symptoms were observed either. So, we can conclude that nasal secretion samples, for eosinophilia percentage determination, should be taken from 2 to 48 hours after nasal provocation, and that the most frequent symptoms, which are probably related to cellular changes, are nasal obstruction and sneezes.


Plasma kallikrein amidolytic activity in bronchial asthma.

We have investigated plasma kallikrein amidolytic activity in the following groups of patients: 1. Normal control group of blood donors. 2. Extrinsic pollen-activated bronchial asthma patients, during periods of symptomatology and at a later time after the spring. 3. Subjects with atopic bronchial asthma in acute phase when admitted to our hospital's emergency room and later when clinically recovered. 4. Subjects with extrinsic bronchial asthma, sensitive to Dermatophagoides pteronyssinus and Dermatophagoides farinae with FEV1 < 80%. 5. Subjects with extrinsic bronchial asthma, sensitive to Dermatophagoides pteronissinus and Dermatophagoides farinae in a state of clinical rest. After 9 minutes of activation, the following results were found, with a significance of p < 0.01: There are significant differences between the normal group and those that we consider the active groups, asthma FEV1 < 80%, pollen-sensitive asthma in springtime and acute asthma. No significant differences exist between the normal group and inactive groups, inactive asthma, pollen-sensitive asthma out of springtime and acute asthma inactive. Significant differences exist in active groups (acute asthma and pollen-sensitive asthma in springtime) when they become inactive (acute asthma inactive and pollen-sensitive asthma out of springtime). The active groups have a higher plasma kallikrein amidolytic activity than both the inactive and control groups.


Mobilization of an intracellular glycoprotein (Mac-1) on monocytes and granulocytes during hemodialysis.

We studied the upregulation of the intracellular glycoprotein Mac-1 (CD11b/CD18, CR3) on monocytes and granulocytes during 36 bicarbonate hemodialyses in 12 patients who were randomly treated with Cuprophan (Cu), Hemophan (He) or Polysulfone (PS; low-flux) membranes. The degree of mobilization of this adhesion protein was related to changes in granulocyte and monocyte count, generation of C3a and production of interleukin-1 beta in plasma. Mac-1 expression on granulocytes was significantly higher after 5 and 15 min of Cu hemodialysis as compared to He or PS dialyses (p < 0.001) and correlated to changes in granulocyte count at 15 min (r = 0.62 and r = 0.76, p < 0.001). No differences in early Mac-1 mobilization on circulating monocytes was observed despite a decrease in cell count. Mac-1 expression on monocytes and granulocytes in the venous blood line at 180 min of treatment was significantly higher during Cu dialysis as compared to He and PS dialyses (p < 0.02 and p < 0.001, respectively). Early generation of C3a was higher in patients on Cu dialysis than in He or PS dialysis (p < 0.001) and correlated both to granulocytopenia (r = 0.45, p < 0.01) and to the subsequent increase in Mac-1 expression on granulocytes (r = 0.63, p < 0.001). An early increase in Mac-1 expression on monocytes was accompanied by an increase in plasma interleukin-1 beta later during dialysis (p < 0.05). Studies of Mac-1 expression during hemodialysis increased the sensitivity of biocompatibility measurements and correlated better than complement generation to changes in granulocyte count as it mediates adhesion to endothelial cells.


Serum levels of the soluble interleukin-2 receptor are dependent on the kidney function.

We have investigated the influence of kidney function on soluble interleukin-2 receptor (S-IL-2R) serum levels. S-IL-2R is a glycoprotein with a molecular weight of 45 kDa. The serum concentration of S-IL-2R was positively correlated to serum creatinine (r = 0.35) and complement factor D (r = 0.30), a low molecular weight protein, and the reciprocal value of S-IL-2R was negatively correlated to 51Cr-EDTA clearance (r = -0.35). When measuring S-IL-2R and factor D in a wide range of serum creatinine (140-1,380 mumol/l), a high positive correlation was found between factor D and serum creatinine. S-IL-2R and serum creatinine had r = 0.92 and r = 0.79, p = 0.0001, respectively. The correlation coefficient between factor D and S-IL-2R was 0.86. S-IL-2R is used as a marker for an increased activity of the immune system and in a variety of lymphoproliferative disorders. However, it is important to keep in mind that a reduced kidney function may contribute to the increased S-IL-2R levels seen in different immune diseases. Therefore, renal function should be taken into account in the interpretation of elevated plasma concentrations of S-IL-2R.


Prospective study on captopril renography in hypertensive patients.

Six hundred and sixty-seven hypertensive patients were analyzed by captopril-enhanced scintigraphy. If time to reach maximal activity (Tmax) was > or = 5 min using 99mTc-diethylenetriaminepentaacetic acid (DTPA) or > or = 3 min with 123I-o-iodohippurate (OIH) and 99mTc-mercaptoacetyltriglycine (MAG3) and washout time > or = 15 min, a control study with nifedipine was performed. If the difference between Tmax under captopril and nifedipine premedication was > or = 5 min with 99mTc-DTPA or > or = 3 min with 123I-OIH and 99mTc-MAG3, the renogram was defined highly suggestive of renovascular hypertension. In the evaluation of bilateral abnormalities an additional parameter was considered, i.e. the presence of functional asymmetry of the emuntories susceptible of partial reversal in the control study under nifedipine. Based on these criteria, 58 out of 667 (8.7%) scintigrams were found to be abnormal. Thirty-five of these 58 patients and 32 of the remaining 609 scintigraphically negative cases underwent additional arteriographic examination. A renal vascular stenosis > or = 50% was found in 33 out of 35 (94.2%) patients with positive scintigraphy and in 3 out of 32 patients with negative scintigraphy. By examining results of the 67 patients undergoing arteriography, the sensitivity of captopril-enhanced scintigraphy was estimated to be 91.6%, with a specificity of 93.5%, an accuracy of 92.5%, and predictive values of a positive or negative result of 94.2 and 90.6%, respectively. By restricting analysis to bilateral stenosis, sensitivity was found to be 76.9%.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of high-flux hemodialysis on quality of life and neuropsychological function in chronic hemodialysis patients.

The objective was to evaluate the effect of high-flux hemodialysis on quality of life, intra- and interdialytic symptoms and neuropsychological function. The study was double-blind single cross-over with random allocation to order of treatment. The patients were stable adult hospital hemodialysis patients. Both the conventional and high-flux membranes were cellulose acetate, the dialysate was bicarbonate, and dialysate sodium was held constant. The high-flux membrane had an ultrafiltration rate of 15 ml/h/mm Hg transmembrane pressure, a B12 clearance of 88 ml/min and a beta 2-microglobulin clearance of 11.4 ml/min. The values of the conventional membrane were 3.5-5.0, 34-45 and negligible. Each treatment period was 4 months. Twenty-two patients completed both phases of the cross-over. The KT/V value was higher during high-flux than conventional treatment; 1.42 versus 1.27(p < 0.05). There were no differences between high-flux and conventional treatment with respect to quality of life. Symptoms during dialysis were less severe during high-flux than conventional treatment for 12/14 items. Only 3 items reached statistical significance (0.05 > p > 0.01) and none were clinically significant. Symptoms between dialyses were less severe during high-flux than conventional treatment for 18/20 items. No single item had a statistically significant improvement but 3 had clinically important improvement. Among the 23 neuropsychological variables, none demonstrated statistically significant changes.


Bisphosphonate kinetics in patients undergoing continuous ambulatory peritoneal dialysis: relations to dynamic bone histomorphometry, osteocalcin and parathyroid hormone.

In the evaluation of renal osteodystrophy bone biopsy is often performed. However, a reliable noninvasive test could be very useful, and recently the estimation of osseous tracer uptake as an index of bone formation has been introduced-the bone bisphosphonate clearance (BBC). The aim of the present investigation therefore was to compare BBC with parameters of bone histology, serum levels of osteocalcin, alkaline phosphatase, and parathyroid hormone in patients (n = 8) undergoing continuous ambulatory peritoneal dialysis (CAPD). No significant correlations were found between BBC values and the bone histomorphometrical variables measured. A positive correlation was seen between serum osteocalcin and resorption and active resorption surface (p < 0.05), as well as tetracycline-labelled surface, bone formation rate, surfaces, volume and tissue referents, respectively (p < 0.01). Furthermore, levels of alkaline phosphatase showed significant correlations to mineral appositional rate, tetracycline-labelled surface and bone formation rate, volume referent (p < 0.05). Values of parathyroid hormone were significantly correlated to resorption surface (p < 0.02), active resorption surface, mineral appositional rate and mineralization lag time (p < 0.05). In conclusion, BBC was of no use in patients treated with CAPD as a noninvasive test for evaluation of bone histomorphometry. However, osteocalcin correlated best with resorption and bone dynamics indices. Levels of alkaline phosphatase and parathyroid hormone were of a more limited value.


Effects of naloxone infusion in patients with septic shock and renal failure: a limited experience.

Septic shock is frequently associated with acute renal failure. Management of these patients becomes complicated if either the renal or systemic hemodynamic derangement cannot be corrected. Although previously large doses of furosemide and naloxone infusion have been used separately in managing these patients, the combination of both agents has not been employed. We therefore report our limited experience with this combined treatment in 5 patients with septic shock, of which 4 had acute renal failure.


Glomerular morphometry of adriamycin-induced focal and segmental glomerulosclerosis in the rat.

The present paper presents a morphometric study of the evolution of the glomerulus in Adriamycin-induced focal and segmental glomerulosclerosis in the rat over 32 weeks. The morphometric parameters studied generally varied significantly when the groups treated with Adriamycin were compared with controls. Glomerular area and perimeter showed an irregular pattern and finally ended up with values similar to those of the control group. Glomerular capillary tuft area and perimeter were always significantly greater in Adriamycin-treated groups than in controls. The mesangial area of treated animals increased over the study period in comparison with that of controls. While the total number of cells in the glomerular capillary tuft had an irregular pattern, the proportion of cells in relation to glomerular capillary tuft area was significantly lower in treated animals than in controls.


Balloon expandable stents to treat central venous stenoses in hemodialysis patients.

Vascular access failure in hemodialysis patients remains a significant problem. The use of thrombolytic agents and balloon angioplasty instead of or in conjunction with surgical revision, has been helpful in increasing the life span of vascular access in these patients. The application of newer endovascular therapies, such as vascular stents, may further improve the salvage rate of hemodialysis access sites. These stents may be particularly valuable in treating stenoses in large central veins. We present 2 cases in which a balloon-expandable Palmaz stent was used to treat a central venous stenosis causing signs of vascular access failure.


Disappearance of immune deposits with EDTA chelation therapy in a case of IgA nephropathy.

In this report, we describe the development of renal function impairment in a 33-year-old patient with mesangial IgA nephropathy and a history of recent gout. Increased body lead burden was identified with a positive EDTA mobilization test. The patient was treated with 1 g of edetate disodium calcium weekly for 2 months until normalization of urinary lead excretion. Improvement of renal function and proteinuria were noted. It was even more interesting to find that both immunofluorescence and electron microscopy studies of the second biopsy specimen revealed the loss of previous mesangial immune deposits. Our case demonstrated that lead may be a nonspecifically damaging factor related to the deterioration of renal function in patients with preexisting renal disease. Moreover, the disappearance of mesangial immune deposits after chelation therapy has not been previously documented. The pathogenetic basis of this observation is unknown, and its causal relationship with lead requires further elucidation.


Chronic hypovolemia associated with accelerated hypertension and orthostatic hypotension in a patient on continuous ambulatory peritoneal dialysis.

We report a patient with nondiabetic end-stage renal disease on continuous ambulatory peritoneal dialysis (CAPD) associated with chronic hypovolemia. Despite the administration of nilvadipine, the patient showed accelerated hypertension and concomitantly orthostatic hypotension. Plasma renin activity was markedly high, and blockade of angiotensin II action by captopril or an angiotension II antagonist decreased the supine blood pressure. This indicated that the enhanced activity of the renin-angiotensin system was the principal cause of the supine hypertension. The plasma concentration of norepinephrine was also very high. After correction of hypovolemia by blood transfusion, the enhancement of the renin-angiotensin system and high plasma norepinephrine level were reduced, and symptomatic orthostatic hypotension disappeared. The accelerated hypertension was easily controlled by the administration of low-dose captopril and nilvadipine. These findings suggest that chronic hypovolemia related to the intractable supine hypertension as well as orthostatic hypotension. Hypovolemia-induced enhancement of the renin-angiotensin system and sympathetic nerve activity may cause vasoconstrictive hypertension in patients on CAPD.


Membranoproliferative glomerulonephritis associated with multicentric angiofollicular lymph node hyperplasia. Case report and review of the literature.

A 14-year-old boy presented with fever, anemia, hepatosplenomegaly, generalized lymphadenopathy and nephrotic syndrome. Lymph node biopsy showed angiofollicular lymph node hyperplasia (generalized Castleman's disease) of the plasma cell type. Kidney biopsy showed membranoproliferative glomerulonephritis type 1. Complete remission was achieved with corticosteroid treatment and repeat kidney biopsy 22 months later showed complete resolution of the renal pathology. The association between membranoproliferative glomerulonephritis and multicentric angiofollicular lymph node hyperplasia, plasma cell type, has not previously been reported.


Effect of recombinant human growth hormone in a postpediatric hemodialysis patient with delayed growth.

We present an 18-year-old patient who has been on renal replacement therapy since the age of 11. He had growth retardation and delayed puberty, with a bone age of 13.6 years. Treatment with human recombinant growth hormone (rhGH) resulted in a clearcut increase in height and lean body mass. We emphasize that rhGH treatment could be tried even at a postpediatric age, provided bone radiology suggests that further growth is possible.


[Pregnancy and labor in women in the region of the accident at the Chernobyl Atomic Electric Power Station].

The authors analyze the tentative results of a multiprofile study, including a review of labor histories, examinations of pregnant women and parturients, measurements of fetoplacental hormones, study of the immunity status and microbiocenosis of the mothers and newborns, living in the first (up to 15 Ci/km2) and second (15 to 40 Ci/km2) zones of radioactive contamination. The detected shifts of a compensatory nature were found mostly in women living in the first zone. The disorders found in the women living in the second zone evidenced a decrease of the defense potential of the body, this necessitating nonspecific and correcting therapy during pregnancy, in labor and the postpartum period.


[The effect of the characteristics of maternal psychological adaptation on the outcome of labor].

The authors analyze the effect of psychologic adaptation of 108 pregnant women to the clinical course of their labor. Psychologic adaptation of pregnant women was assessed by the method of comprehensive personality analysis (the adapted variant of the Minnesota personality questionnaire). Two groups of women were distinguished: Group 1, 30 women (27.7%) with effective psychologic adaptation and Group 2, 78 women (72.3%) with disordered psychologic adaptation abilities. Disco-ordination of the uterine contractions (primary and secondary uterine inertia, early rupture of amniotic membranes, abnormal preliminary period), fetal and neonatal hypoxia, injuries to the soft tissues of the birth routes were more often observed in Group 2 women than in Group 1.


[The acupuncture prevention of anomalies in labor strength in pregnant women of a risk group].

Acupuncture was carried out for 3-6 days in the course of preparation to labor of 80 pregnant women at risk of developing labor activity abnormalities. Pulmonary, renal, gastric meridians, anteromedian and auricular points were used. Acupuncture was conductive to improvement of the autonomic nervous system activity with the predominance of the cholinergic component. The course of spontaneous labor was normal and blood loss was significantly lower than in puerperae not administered acupuncture.


[A clinico-experimental study of the tocolytic properties of salbupart in treating threatened abortion].

Clinical and experimental studies have revealed that salbupart, a beta-mimetic agent, administered in a dose of 0.14 mg/kg (the maximal therapeutic dose) markedly inhibited the spontaneous and oxytocin-induced uterine contractility, caused no embryotoxic or teratogenic effects, and did not influence fetal growth and development. The efficacy of salbupart tocolytic therapy was estimated as 75%. Blood plasma cAMP levels normalized in the pregnant women over the course of therapy. Clinical and experimental results recommend salbupart for pregnancy protecting therapy in cases with threatened spontaneous abortions.


[New aspects of the surgical procedure in abdominal delivery].

A single-row suturing of the incision on the uterus after cesarean section with separate muscular-muscular sutures by synthetic dissolving threads holds good promise. Such suturing helped optimize the reparative processes in the uterine cicatrix and reduce the incidence of postoperative pyoseptic complications. Kaproag, an antibacterial suture material made in this country, proved to be the best for the purpose.


[The ultrasonic diagnosis of intrauterine fetal growth retardation].

A total of 256 pregnant women were examined in pregnancy terms of 19-40 weeks. Besides routine fetometric parameters, the transverse diameter of the cerebellum was measured in the fetuses. This parameter was in good correlation with the gestational age. In 42 cases with small-for-date fetuses the transverse diameter of the cerebellum did not much differ from that in the reference group. Therefore measurement of the transverse diameter of the cerebellum is a truly good method for the assessment of the gestational age, for it is virtually independent of all the pathologic processes in the mother or fetus.


[The ultrasonic antenatal diagnosis of rarely encountered tumors in fetuses and the procedure for managing the pregnancy and labor].

Ultrasonic examinations of 3000 pregnant women revealed congenital developmental defects in 22 (0.7%) fetuses: in 4 cases tumors of various sites were detected and in 2 cases the tumors were found in one of the twins. Pathologic and histologic examinations carried out after delivery revealed a sacrococcygeal teratoma and a retroperitoneal dermoid cyst in one fetus, a ganglioneuroma of the retroperitoneal space, located between the bladder and rectum, an intrapericardial teratoblastoma, and a cystic cervical lymphangioma. The latter three tumors were responsible for nonimmune fetal edema. In one case an abortion was induced at pregnancy term of 22 weeks. Three fetuses died after deliveries in various terms. Based on his own experience and the literature data, the author suggests recommendations on the policy of following up the pregnancy and labor in various periods of gestation with different number of fetuses with due consideration for the tumor size and the fetal state, as well as on the possible correction after birth.


[Fractures as a possible complication of osteoporosis in women in the climacteric].

The author has analyzed the incidence of bone fractures in women of various age groups, residents of the Cheryomushki District of Moscow in 1988-1989, using the records of the traumatologic service of the district and the census data. The incidence of bone fractures was the highest in women aged over 45 (up to 2.5%), and was the higher the older the woman grew, 2/3 of all the fractures occurred in women aged 45-64. Analysis of the findings has confirmed that the developing postmenopausal osteoporosis, that was not diagnosed in time and therefore not prevented, contributed to the occurrence of bone fractures in women aged 45 to 65. The author emphasizes the necessity of studying osteoporosis incidence in various age groups and the share of this condition in women with fractures, making use of the monophoton absorptiometry.


[A clinical trial of a monophasic contraceptive preparation containing ethinyl estradiol and desogestrel].

A multicenter trial was conducted in 267 centers in Italy to evaluate the efficacy, acceptability and safety of a monophasic oral contraceptive containing 30 micrograms ethinyl estradiol and 150 micrograms desogestrel (Marvelon). 13,290 women were followed up for a total of 74,967 cycles. No pregnancies due to method failure were reported and only three because of patient failure. Cycle control was good. There was a decrease in the occurrence of irregular cycles and in the duration and amount of menstrual bleeding; the incidence of breakthrough bleeding and spotting was low. No severe side effects occurred and the incidence of minor complaints was generally lower during treatment than in the pretreatment cycle. Body weight and blood pressure were not significantly altered.


[Changes in the indices of the immune and protease inhibitor systems in physiological pregnancy].

Studies of the immune and enzymic homeostasis in 26 healthy nonpregnant women and in 30 healthy pregnant women in the course of pregnancy and on days 2-3 after normal labor have revealed that the T immunity system was liable to changes over the course of pregnancy to a greater measure than the B system. A significant elevation of the neutral proteinase activity and slight fluctuations in acid proteinase activities were seen in pregnant women as against nonpregnant ones. Immunoglobulins A, M, G, circulating immune complexes levels and elastase activity and the total activity of antiproteinases were virtually unchanged in pregnancy.


Stereo architecture of the connective tissue cores of the lingual papillae in the treeshrew (Tupaia glis).

The stereo architecture of the lingual connective tissue cores (CTC) in the treeshrew (Tupaia glis) (which has the primitive characteristics of primates) was observed by scanning electron microscopy, and compared to that of other animal orders. The tongue of the treeshrew has three vallate papillae which are situated in the posterior part of the tongue, while some macaques have several vallate papillae. Among numerous filiform papillae, fungiform papillae are sporadically distributed. A filiform papilla consists of a bundle of several slender spine-like processes arranged in a circle at the basal margin. After removal of the epithelium, the CTC of the filiform papilla looks like a human hand raised with the palm facing towards the tongue tip. The fungiform CTC in the threeshrew is columnar in shape (rather similar to that of Insectivora and Rodentia) and at the top there are several round depressions for taste buds. In the treeshrew several large rod-shaped processes are derived from the postero-lateral margin of the tongue, as in Carnivora (dogs and cats), where foliate papillae are located in many other animal species. The treeshrew has numerous characteristics similar to those of the crab-eating macaque (Primates), but at the same time it has some characteristics similar to those of Insectivora, Rodentia, Carnivora and Artiodactyla.


The cellular network of interstitial cells associated with the deep muscular plexus of the guinea pig small intestine.

Systematic examination using electron microscopic montages and serial sections has demonstrated that three types of interstitial cell, namely gap junction-rich cells, glycogen-rich cells and fibroblast-like cells, are densely located along the whole extent of the deep muscular plexus of the guinea pig small intestine. They tend to be distributed in an alternating fashion in the cellular network, connected with muscle cells of the outer, circular layer by means of gap junctions. These three types of interstitial cell show close relations to two types of nerve varicosity: one type is characterized by clear round vesicles with diameters of about 50 nm, and the other by flattened vesicles measuring about 35 nm by 70 nm. Electron-dense patches have been observed at the cytoplasmic side of the axonal membranes. Muscle cells of both inner and outer circular layers also show close relations to these two types of nerve varicosity. These morphological features are discussed with the implication that they may have some regulatory role in intestinal movement.


Ultrastructural localization of calcium in the chick chorioallantoic membrane as revealed by cytochemistry and X-ray microanalysis.

The chorioallantoic membrane (CAM) of the chick embryo actively transports calcium from the egg shell into the embryonic circulation. To investigate the intracellular pathway of calcium transport across the CAM, ultrastructural localization of intracellular calcium in cells of the chorionic ectoderm (CE) was determined using cytochemical methods and X-ray microanalysis. Treatment of the CE with potassium oxalate, potassium ferricyanide or potassium pyroantimonate revealed large numbers of electron-dense granules (EDGs) in the ectodermal cells. These measure 30-40 nm in diameter, and are not membrane-bound. These granules were seen in all three cell types of the CE. The presence of calcium in the EDG was directly confirmed by X-ray microanalysis. When strontium or barium ions were applied to the shell membrane side of the CAM, the cells of the CE incorporated these divalent cations and sequestered them in granules (25-40 nm in diameter) in cytoplasm and mitochondria. This study indicates that calcium enters the CE cells by means other than endocytosis, as the EDGs are not membrane-bound, that all three types of the CE cells appear to function in transport of calcium from shell to embryo during embryogenesis, and that the EDG plays important roles in intracellular accumulation of calcium during the process of calcium transport across the chorioallantoic membrane.


Human mandibular prenatal growth: bivariate and multivariate growth allometry comparing different mandibular dimensions.

Mandibular growth was studied in 36 human fetuses (both sexes) ranging from 13 to 37 weeks of gestation by bivariate and multivariate analyses (bivariate allometry and principal components analysis, PCA). Several mandibular dimensions were measured and correlated with fetal weight. Considering the different mandibular dimensions in sequence of increasing component weights, PCA agreed with bivariate analysis. No mandibular dimension was considered to increase in isometric relationship. PCA showed the following distances with negative allometry: caput mandibulae-gnathion (both sides), gonion-processus coronoideus (both sides), caput mandibulae-processus coronoideus (both sides) and gonion-gnathion (right side). On the other hand, the following dimensions grew with positive allometry: gonion-gnathion (left side) and symphyseal height (both sides). PCA and bivariate analysis showed higher growth rates for the gonion-processus coronoideus distance and symphyseal height on the right side than on the left. All other mandibular dimensions presented more elevated growth rates on the left than on the right side. During the second and third trimesters of prenatal life the mandibular growth was allometrical; the mandibular body grew with more intensity than the ramus in both length and height. The greatest growth rate was found for the height at the symphysis. The angulus mandibulae presented a negative and slight correlation with the other linear dimensions of the mandible during prenatal life.


Ultrastructural and immunocytochemical study of the myoendocrine cells of the fish Hypostomus cordovae.

The myoendocrine cells of the heart of Hypostomus cordovae (Günther 1880), a teleost fish from South America, were investigated by electron microscopy and immunohistochemistry. By applying antibodies raised against synthetic cardiodilatin 99-126 (CDD/ANP 99-126), a specific labeling of this hormone was found in the heart of this fish, mainly in myoendocrine cells of atrial trabeculae, where specific secretory granules are stored. The distribution of secretory granules exhibited striking seasonal variations. In winter there were fewer differentiated myoendocrine cells, which were easily recognized by the presence of specific secretory granules, most of which occur clustered in perinuclear areas of the cells. By contrast, in summer the majority of the myocardic cells of the atrium are active endocrine cells. They contain abundant secretory granules widely scattered in the cytoplasm, many of them polarized toward the subendocardial aspect of the cell. The secretory granules can be easily differentiated from the Weibel-Palade granules of endothelial cells, the shape, size and content of which were typical at electron-microscopic level. In addition, these endothelial granules did not display CDD immunoreactivity. The presence of cardiodilatin in a fish such as Hypostomus cordovae further supports the view that cardiac hormones are present in many Vertebrates and may preserve analogous roles such as those reported in other species throughout the group.


Number and size-spectra of myelinated nerve fibers of human premolars.

The primary objective of this study was to determine the number and size of myelinated nerve fibers at the subcervical, midroot and juxta-apical levels of human premolars. Sixty-seven healthy premolars extracted from adolescents were utilized. Root-discs were prepared from the three sites and processed for light and electron microscopy. The myelinated nerve fibers were counted from semithin sections using a sampling microscope. The measurements were taken from composite electron micrographs using an electronic image processing unit. A total of 1883 myelinated axons from seven mandibular second premolars was gauged. The 67 teeth had an average of 312 +/- 149 myelinated nerve fibers at the juxta-apical level (range 18 to 728). The contra- and ipsilateral differences in means among the four groups of premolars were not significant (P > 0.05). The number of nerves increased significantly (P < 0.05) toward midroot and subcervical (P < 0.001) levels in all groups. The average neural diameter was 3.5 + 1.0 microns at the juxta-apical level, and the between-teeth difference in mean was found to be significant (P < 0.01). There was no decline (P > 0.05) in the diameter of myelinated nerve fibers toward midroot and subcervical levels.


An ultrastructural study of myoepithelium maturation during postnatal development of the hamster Harderian gland.

This study reports the ultrastructural cell modifications in the myoepithelium of the Harderian gland during the postnatal development of the Syrian hamster. Tissues were obtained from male and female hamsters at days 1, 3, 5, 7, 10, 12, 15, 17, 20, 27, 37, 46 and 90 after birth, and processed for transmission electron microscopy. Electron microscopy was coupled with point counting methods to quantitate changes in several subcellular organelles during the course of myoepithelial cell maturation. The myoepithelial cells in this gland remained immature at birth. The earliest age of development when organized bundles of microfilaments were observed was 7 days. By the 12th day, the myoepithelial cells had developed most of their specific characteristics and resembled the mature form. Myoepithelial cells mature synchronously with each other and with the secretory cells. No undifferentiated myoepithelial and myoepithelial cells, the secretory endpieces of the adult hamster Harderian gland contain a third cell type which resembles the myoepithelial cell in shape and has an extremely electron-lucent cytoplasm lacking microfilament bundles.


Fiber order in the opossum's optic tract.

The distribution of axons by size in the optic tract of the South American opossum, Didelphis marsupialis was studied. Thin and semi-thin sections were examined, and measurements of axonal diameter were made on electron micrographs taken from various locations across the optic tract of normal opossums. In order to determine the contributions of the different axon diameter classes to the crossed and uncrossed retinofugal pathways, measurements were also made from the tracts of opossums in which one eye had been enucleated 5 weeks previously. Within the opossum's optic tract, the axons are partially segregated by their size: the deepest parts of the tract contain only fine and medium-sized axons, whereas coarse axons are also present superficially. In the middle of the tract, all three size classes are present. At increasingly superficial positions, there is a steady reduction in the proportion of medium-diameter axons, and an increase in the number of the finest axons. Medium and coarse axons contribute to both the crossed and uncrossed pathways, and the uncrossed component is displaced superficially relative to the crossed component. The fine axons in the deeper parts of the tract arise from both retinae, while those in the superficial parts of the tract, near the pial surface, are virtually all crossed. The opossum's optic tract thus displays the segregation of axons by size found in placental mammals, and follows a pattern reminiscent of that found in carnivores. Such a common organizational plan, particularly the similarities between the didelphids and carnivores, is suggestive of an early acquisition of parallel visual pathways in mammalian phylogeny. Since the fiber order in the optic tract of eutherians is a chronological map of axonal arrival during development, these results suggest that a conserved developmental mechanism has led to a common organizational plan.


Development and ageing of phenotypically distinct fibrocartilages associated with the rat Achilles tendon.

We describe by routine histology and by immunohistochemistry three phenotypically and developmentally distinct fibrocartilages associated with the Achilles tendon of the rat. All the fibrocartilages develop after birth and show significant age-related changes in the composition of their extracellular matrix. Attachment-zone fibrocartilage occurs at the insertion of the tendon on the calcaneus. It derives from the cartilage rudiment of the calcaneus and from the region where the tendon merges with the perichondrium. The extracellular matrix contain type II collagen and chondroitin sulphate. Compressive tendon fibrocartilage occurs in the deep part of the tendon where it presses against the calcaneus, and is derived by metaplasia of tendon cells. The cells label strongly for the intermediate filament vimentin, and the extracellular matrix contains chondroitin and keratan sulphates, but type II collagen only in very old animals (> 2 years). Calcaneal fibrocartilage covered the posterior surface of the calcaneus where it was in contact with the Achilles tendon. It labelled intensely for type II collagen and contained chondroitin and keratan sulphates. The cells were rich in vimentin. This fibrocartilage was derived from the calcaneal perichondrium.


[Intra- and extracranial nasopharyngeal fibroma. Contribution of imaging and study of local failure. Report on 34 patients].

Thirty-four patients with nasopharyngeal angiofibroma were treated between 1975 and 1990. Lesions were classed according to Sessions' classification. 17 showed intracranial extension. Treatment always associated embolization and surgical excision using a transfacial approach and, if necessary, neurosurgical techniques. A total of 13 patients (38.2%) developed recurrent lesions; these included 3 (17.6%) patients in the extracranial group and 10 (58.8%) patients in the intracranial group. Erosion of the clivus and displacement of the cavernous sinus seem to be 2 factors significantly associated with the development of recurrent lesions. Symptomatic recurrences were managed by surgery. Close clinical and radiological follow-up of patients with asymptomatic recurrent tumor made it possible to observe the stabilization, or even, the regression of the tumor. This study also underlines the importance of modern diagnostic and interventional imaging, which makes it possible to better determine tumor extension and to perform highly selective embolizations. Modern imaging also detects recurrences which once would have remained unknown because of their small size and the absence of symptoms. The techniques of embolization of the tumor branches from the internal and external carotid arteries are explained. Finally, our results are compared to those published in the literature.


[Partial posterior cordectomy with laser CO2 in bilateral recurrent paralysis].

Thirteen patients with bilateral vocal cord abductor paralysis were treated by Carbon Dioxide Laser Posterior Cordectomy. 6 out of 7 patients were decannulated. 92% of patients recovered a physiologic respiration. Advantages of this surgical technique are discussed in comparison with Endoscopic Laser Arytenoidectomy.


[Cervical branchiomeric paraganglioma. Report of 21 cases].

Over the last 24 years the authors operated 21 branchiomeric paragangliomas in 18 patients. They emphasize the difficulty of making the diagnosis and the importance of completing a thorough work-up before deciding surgery. Adequate imaging is particularly important (neck sonography, computed tomography, arteriography) to avoid making the diagnosis by exploratory neck dissection and to assess the vascular risk. Biological studies have regained importance, especially in the context of complex neuro-cristopathy. Treatment is essentially surgical and must be considered with prudence in patients with bilateral lesions. The surgical removal of branchiomeric paragangliomas necessitates preparation of a small saphenous vein bypass in case it is not possible to avoid sacrificing the internal carotid artery.


[Revision intranasal sphenoethmoidectomy in recurrent nasosinusal diseases especially polyposis].

A 16 case series of intranasal revision sphenoidecthmoidectomies is presented in this study concerning 10 patients with recurrent polyposis after 245 intranasal ethmoidectomies performed between 1986 and 1990 (6.5%). The modalities of surgical decision are precisely described, pointing out the correlation between clinic and endoscopic arguments. The CT-Scan is particularly appreciated for the details of recurrence sites and the anatomical dangers along these recurrences. Comparison is established with the most recent publications in this field and the discussion is open to express the rules of this surgery. 80% of good and excellent results are obtained in this series, justifying the procedure. The causes of bad results are evocated, especially allergy and the age of polyposis.


[Long-term follow-up and therapeutic results of the protocol of the National Society of Internal Medicine in centrofacial malignant granuloma. Report of 40 cases].

We have studied 40 cases of mediofacial necrosis with no specific diagnosis on biopsy. After an exhaustive work-up we reached a specific diagnosis in 13 patients (Wegener's granulomatosis in 7, classical malignant lymphoma of the nose in 3, squamous cell carcinoma = "goundou" in 1, syphilis and tuberculosis in 1, aspergillosis in 1). Those patients received the appropriate treatments with good results. The remaining 27 patients, however, had ulcerative lymphomas of the midface (according to the immunofluorescence and molecular biology techniques). Their fate was worse since only 15% remain alive on the long-term, despite intensive treatments with chemotherapy, radiotherapy, interferon, artificial nutrition and antibiotics as needed. We present a new protocol with intensified chemotherapy and growth factor treatment in order to ameliorate the very poor prognosis of these patients.


[Cystic lymphatic malformations of the head and neck. Role of interventional radiology].

Cystic lymphatic malformations are hemodynamically inactive vascular malformations of the lymphatic compartment. Over a 9 years period, 52 patients with superficial cystic lymphatic malformations of the head and neck underwent embolization by direct injections of Ethibloc (Ethicon, Ethnon Laboratories, Neuilly/France) under fluoroscopic control. Results were graded as excellent or good in 57% of patients after embolization alone. Treatment was completed by surgery in 19% of patients. Embolization was considered a failure in 24% (12 patients), although 10 of these patients showed regression of the cystic component after embolization. This safe, efficacious percutaneous technique has emerged as the first treatment to be considered for cystic lymphatic malformations.


[Secretory eosinophilia and obstructive rhinitis].

Detecting eosinophilia in the nasal secretions of patients complaining of nasal obstruction makes it possible to identify a group of high risk patients. Hosty use of surgery in these patients carries a high risk of iatrogenic complications and little potential for improvement. The 2 most frequently used methods of obtaining cytologic specimens (swabbing versus washing) were compared in 37 patients with obstructive rhinitis (early stage polyposis and nonallergic rhinitis with eosinophilia syndrome, NARES). Swabbing gave reliable results. Eosinophilia was negligible in a group of 25 control subjects. The mean eosinophil count was 2.5% and only 1 patient had a positive cystogram. The 220 patients which nasal obstruction were classed in 5 groups according to the severity of clinical signs and symptoms. The mean eosinophil count and the percentage of patients with positive cystogram increased with increased severity of the clinical syndrome. 28 patients had uncomplicated obstructive rhinitis, 10 had NARES, 43 had allergic rhinitis, 52 had chronic obstructive rhinitis, and 87 had nasosinal polyposis. The respective mean eosinophil counts were 6.42%, 10.3%, 13.8% 16.8% and 31.4%. The percentage of patients with positive cytograms was respectively, 10.8%, 20%, 23.3%, 28.8% and 54%.


[Treatment of epistaxis in Rendu-Osler disease by intramucosal injection of ethibloc].

The authors relate their one-year experience in percutaneous embolization of 12 patients presenting with severe epistaxis because of a Rendu Osler disease. Using Ethibloc a sclerosing substance derived from maize in direct intramucosal injection seems to be a promising technique. Ethibloc is still used successfully in percutaneous treatment of superficial venous angiomas.


The burned ear (I): An experimental study with the rabbit model to evaluate scalding temperature, surface and histopathologic appearance, and healing responses with depth of injury.

There are few papers on experimental burns of the external ear. An experimental model was made and a study was conducted on 18 white rabbits to evaluate the response of the rabbit ear in relation to temperature, surface and histologic appearances and healing response with depth of injury. The rabbit model showed that: a) the rabbit ear resembled that of the human ear in histological structure. b) there was a definite correlation of the temperature of the scalding agent with the depth of the injury. c) it was possible to classify morphologically the depth of injury based on surface appearance. d) there was an accurate morphologic correlation with that of histopathologic assessment of burns depth. e) the sequential biopsy at different times (immediate, third, fifth day) showed that the depth of the burns was already apparent soon after the injury. f) there was also a correlation of burns depth with the rate of ear healing.


The burned ear (II): A prospective clinical study of 100 patients with 150 ear burns.

A prospective clinical study of 100 patients with 150 ear burns was carried out in the Burns Centre, Singapore General Hospital. The aims of this study were to document the nature of the injury, the results of various methods of treatment, the complications of ear burns and the changes that led to chondritis. Based on the findings of the experimental studies on the burned ear, it is possible to accurately classify the depth of the burn injury based on the surface appearance. The results show that fire was the commonest aetiologic agent for ear burns (65% cases) and hot water scalds second (25% cases). Scalds tended to cause unilateral ear burns whilst fire caused bilateral injuries. The single most important factor in healing of the burned ear was the depth of the injury. Erythema took six days, mid-dermal (MD) burns ten days, uncomplicated deep-dermal (DD) and full thickness (FT) burns 35 days. When chondritis developed deep dermal burns took 43.5 days to heal and full thickness burns took 57.8 days. Conservative treatment of 104 ears resulted in complete healing except for 15 which had pigmentary and/or hypertrophic scar problems. Surgical treatment was used in 23 ears. Three returned to normal appearance, eleven had mild and four had moderate deformities. Five ears were lost (3% cases). Chondritis was present in 12 ears (8% cases), six in DD and six in FT burns. Seven of these ears were successfully salvaged. Favourable results in this study were attributed to the following factors: early detection of chondritis by the EAR SPRINGING SIGN, early surgical intervention, radical cartilage removal, meticulous post-op care to prevent cross infection and avoidance of pressure to the ears.


Epidemiology and management of respiratory burns in National Burns Centre, Singapore.

Respiratory burns constitute one of the two leading causes of burns mortality today, the other being infection. When cutaneous burns are complicated by co-existent respiratory or inhalational injury, the mortality remains high in most reported series. We began our prospective study of respiratory burns in 1982 as a multi-disciplinary team effort involving respiratory physicians, anaesthetists and our burns physicians. Between 1982 until February 1990, we treated a total of 240 patients with respiratory burns. During the same period, a total of 4041 patients were admitted to our Burns Centre at Singapore General Hospital. Respiratory burns cases therefore constituted 5.4% of the total burns admissions. In our series, there were 44 deaths out of 240 patients, giving an overall mortality of 18.3%. The average size of burns in the patients who died was 57.4% BSA in Group A patients, 65.0% BSA in Group B and 57.7% BSA in Group C. Our management protocol has gradually evolved over the eight years of the study. Systemic antibiotics and steroids are no longer used routinely. Fiberoptic bronchoscopy is done early in the ward as a bedside procedure once a patient is clinically assessed to have suffered a respiratory burns and repeat bronchoscopic examination done when deemed necessary. An aggressive regime of respiratory support measures with early intubation and PEEP ventilation is recommended.


Morbidity and mortality in respiratory burns--a prospective study of 240 cases.

A prospective study of 240 consecutive admissions with respiratory burns over an eight-year period beginning 1982 was carried out at the National Burns Centre, Singapore General Hospital. Diagnosis of respiratory burns was based on clinical criteria and a clinical score was then computed to grade the severity. Investigations included chest x-rays, blood gases, carboxyhaemoglobin level, lung scan and fibreoptic bronchoscopy. Treatment was carried out according to a standard protocol where a policy of early intervention in the form of endotracheal intubation was emphasised. Other respiratory support measures were chest physiotherapy, tracheobronchial suction, mucolytics and bronchoscopic lavage where indicated. We found that respiratory burns was a significant cause of mortality in burns patients. The influence on mortality was most marked in patients with large body surface area burns of more than 40%. Age was also an important determinant of survival with patients older than 50 years faring significantly worse. The routine steroids and prophylactic antibiotics did not influence the survival rate. Carbon monoxide poisoning was not a significant cause of mortality. We achieved an overall mortality rate of 18.3%, with 44 deaths out of 240 patients. The main causes of deaths at post-mortem were bronchopneumonia, septicaemia and extensive burns.


Mass ammonia inhalational burns--experience in the management of 12 patients.

Twelve Korean crew members of a deep sea fishing vessel were admitted to the Burns Centre, Singapore General Hospital following exposure to ammonia gas. The injuries sustained were primarily respiratory burns with minor cutaneous and corneal burns. They were divided into three grades of severity based on the admission findings and subsequent clinical course. Management was according to a standard respiratory burns protocol. Eight patients were intubated. Ten of the patients with mild and moderate involvement of the respiratory tract recovered without complication. Of the two patients with severe respiratory burns, one died while another progressed to chronic debilitating airway disease.


Radionuclide lung scanning in the management of respiratory burns.

Soluble radioaerosols such as technetium-99m diethylene triamine pentacetate (DTPA) permit simple quantitative studies of alveolar-capillary permeability to be performed, since the submicronic aerosols are deposited mainly at the lung periphery and are cleared across the alveolar-capillary membrane. Regional alterations in permeability can also be noted using this radionuclide technique. We have measured the alteration in pulmonary epithelial permeability in normal subjects and in patients with inhalation burns using a computer-linked gamma-camera. In the normal volunteers, the time taken for 50% of inhaled Tc-99m DTPA to be cleared from the lungs (T1/2) was 66 minutes +/- 1sd of 12 minutes. In the 42 patients with inhalation burns, besides the T1/2, retention images of uncleared Tc-99m DTPA in the lungs were obtained to note regional differences, if any, in lung clearance arising from pulmonary epithelial damage; these patients showed increased rate of clearance (short T1/2) with mean T1/2 of 36 minutes +/- 1sd of 11 minutes, while the retention images revealed regional lung damage in moderately severe inhalation burns. In 18 patients with abnormal T1/2, 16 (89%) had abnormal bronchoscopy findings. Fifteen patients also had lung perfusion scans with Tc-99m MAA (macroaggregated albumin). The regional defects in perfusion when present were generally matched with the defects seen on ventilation scans. The Tc-99m DTPA lung clearance measurement and imaging has clinical usefulness in suspected inhalation burns.


Burns mass disasters: aetiology, predisposing situations and initial management.

Many agents that are encountered daily are liable to cause burns mass disasters. These include flames, hot water and steam, combustible gases and liquids, molten liquids, boiling liquid expanding vapour explosion, chemicals and explosives. They result in disaster when certain lacks in safety occur. The proper management of such burns victims begins with rescue. At the disaster site, triage is important to separate the living from the dead, decide on priorisation for initial treatment and then evacuation to an appropriate facility. Proper management requires team effort and should be continued en-route to hospital. Repeat triage and use of clear guidelines in the Emergency Department ensure optimal and rapid care of the casualties. Finally psychological support for victims, relatives, rescuers and health workers must not be forgotten.


Anatomy of a burns disaster: the Miri Bank explosion.

A bank explosion in a neighbouring country over 1000 km away resulted in ten badly burned victims being airlifted to the Burns Centre, Singapore General Hospital (BCSGH) for treatment. The severely injured included patients with 90%, 80%, 74%, 66%, 45%, 33% and 31% burns. Nine had respiratory burns (four severe, one moderate, four mild). One patient died, thus, the mortality rate for the six most severely injured was 16.7%. This differs from predicted mortality rates of 78% according to McCoy or 54% according to Thompson, Herndon et al. The factors contributing to this result were the small size of the disaster, the use of an established Burns Mass Disaster plan and an individual management policy that incorporates carefully monitored fluid resuscitation, recognition of respiratory burns with early treatment by intubation thus pre emptying complications, early surgery and a multidisciplinary approach to complications such as infection and renal failure. The average length of stay was 43 days (range 5-122 days). The cost of the hospitalisation of the ten casualties was $312,317.00.


Forensic investigation of deaths due to fire in mass disaster.

When a body is recovered from a fire site, it is essential to determine if death occurred before or after the fire started. Foul play is suspected when there is an alternative cause of death not due to the fire. In cases of mass disaster due to fire, the forensic pathologist has an additional task of identifying the bodies. This is important in medico-legal investigations. The severity of the burnt injuries sustained may be useful in the reconstruction of the incidence. Examples will be given in this paper on the identification of the burnt victims and the forensic investigations on death by fire in mass disasters.


The prevalence of invasive candidiasis in patients with extensive burns.

A retrospective study of patients admitted to the Singapore General Hospital Burn Unit with > 30% total body surface area burns was performed to establish the prevalence of fungal colonisation and invasive fungal disease (IFD). Forty-eight percent of patients surviving at least ten days following thermal injury had fungi isolated. IFD was documented in ten patients. Risk factors associated with the development of IFD, clues to assist in diagnosing IFD, and therapeutic options for managing IFD are reviewed.


Emergence of a multiply-resistant strain of Acinetobacter in a burns unit.

Multiply-resistant Acinetobacter has emerged as an important organism in the Burns Unit of the Singapore General Hospital. From November 1990 onwards, a strain that was resistant to all antibiotics except Polymyxin B emerged in the Burns Unit. We present two cases where the Acinetobacter isolated was resistant to all antibiotics including Polymyxin B. These cases serve as an important reminder to adhere to strict infection control procedures.


Multiple resistant Staphylococcus aureus.

Burn wound sepsis is still a common cause of death in burn injuries. Eighty percent of this infection is with colonisation from the patient and twenty percent as a result of cross infection. Most of the mortality is due to virulent cross infection. Pseudomonas has almost disappeared and multiple resistant staphylococcus aureus is the main pathogen today. It can cause loss of skin grafts and septicaemia, particularly due to colonisation of intravenous lines. The risk increases with the time since the burn injury. Early excision and grafting is important. With a large burn it is not possible to do this in one session and so the risk is increased with a compromised patient. Maintenance of a good diet and vitamin supplements is important, preferably orally or through a naso-gastric tube. Parenteral nutrition increases the risk of infection. Clinical infection is combated by good cleaning procedures, preferably with chlorhexidine solution and the application of a good topical agent such as Silvazine. The presence of bacteria in the wound must be monitored. Strict barrier nursing and personal hygiene, particularly hand washing, are the mainstay of cross infection prevention. Antibiotics may be required, monitored by blood cultures. Documenting MRSA is a good way to monitor the unit's infection prevention programme. The main preventive measures are early referral, early excision and grafting, good nutritional support, good topical agents and barrier nursing.


Epidemiology of burns in Singapore children--an 11-year study of 2288 patients.

A retrospective review of 2288 children (12 years and below) admitted to the Burns Centre, Singapore General Hospital over an eleven year period (1978-1988) was made. Annual admissions from 1978-85 ranged from 208-290 cases annually (32-38% of all admissions). Between 1986 to 1988 annual admissions ranged from 73-104 cases annually (22-28% of all admissions). There was a reduction of number as well as proportion of children admitted. The main reasons for this change in trend were due to the successful nationwide campaign on fire and home accident prevention, change in admission policy and introduction of newer dressings to treat smaller burns. Boys accounted for 62% admissions. Toddlers between the age of one to two were most vulnerable (26% admission) and children under three years of age accounted for 50% admissions. Eighty-five percent of burns admitted were 10% or less. Length of stay ranged 8-12 days. The commonest cause of injury was scalds (90%) and flame burns (6%). Flame was responsible for the death of six children and scalds of three children. There were nine deaths in this series giving a mortality of 0.4%. Children mortality contributed to 5.6% of total mortality seen in our burns centre. Age per se did not contribute to a higher mortality. There was a definite correlation of mortality to extent of burns. Only one child died from burns of less than 40%. Case mortality in the 40-60% burns group was around 20% and it increased sharply when extent of burns reached or exceeded 70%. Burns in children exhibit anatomical, physiological, surgical, rehabilitative and psychological differences when compared to adults.


Psychiatric disorders associated with burns.

A study was made of burns patients who were referred for psychiatric problems. There were a total of 69 subjects, divided into three groups. The first group comprised thirty-four cases who attempted suicide by burning themselves--there were more women than men, the majority were less than forty years, and Indians were overrepresented. The majority of these were suffering from schizophrenia or a major depressive disorder. The second group of twenty-three patients were those who had a non-psychotic psychological reaction to their burns. The majority were also less than 40 years of age, and the main reactions were anxiety neurosis or reactive depression. The third group of twelve patients were suffering from delirium. All were pyrexic and in eleven, infective agents were cultured. Some of them also had electrolyte abnormalities and two had respiratory burns.


Going deep into chemical burns.

This is a five year retrospective study of chemical burn injury in our burn center between 1 January 1987 and 31 December 1991. Of the 1,226 total burn cases, 131 patients had chemical burns. We noted a constant prevailing incidence of 10.7% per year. Males (72%) are more common than females (28%). Most of those injured are in the working age group (65%). Majority of cases had deep full thickness burn involving less than 10% of their total body surface area. Sulfuric acid is the most common chemical agent encountered. We had three mortality cases with deep third degree burns covering 60% of their total body surface area. Some clinical cases are demonstrated. Lastly, proposed solutions for the prevention of chemical burns are cited.


Escharotomy in burns.

The need for escharotomies is relatively common in the treatment of burn injuries. The need arises because the tight eschar may interfere with the circulation to a limb causing demarcation and loss of the limb or in the case of the chest, may cause interference with respiration such that the expansion in the lungs is interfered with causing atelectasis and pneumonia. In the neck the oedema in the tissue may cause obstruction to the trachea. Indications for escharotomy rest on clinical grounds with tension in the limb under the burn and the state of circulation to the periphery being important. Added to this is the use of Doppler ultrasound, clinical presence of peripheral pulses and at times compartmental pressure measurements. The aim of the escharotomy is to release the pressure over the involved deeper tissues and to restore their circulation. Under sterile conditions make incisions through the eschar until the tissue gapes such as to release the pressure particularly on the vascular supply. These should avoid flexion increases and be designed to release pressure in all compartments if necessary. In the case of electrical burns this may need to be combined with a fasciotomy for diagnostic and therapeutic purposes. Bleeding must be controlled and the escharotomy is then treated as a burn injury being packed with Silvazine cream. Elevation of the limbs is important also to help limit the oedema.


Skin graft and skin equivalent in burns.

The problem in extensive burns is the relative lack of available donor sites for skin grafting. Before the burnt areas can be covered, infection often sets in and the patients may then succumb. Skin grafts can be expanded in a limited way. Biological dressings or synthetic dressings can be used to buy time till donor sites become available. Cultured epithelium grown in the tissue culture laboratory permits massive expansion of skin and has been used with success as epithelial autografts in patients. Composite skin equivalents or skin substitutes have been developed and show promise.


Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow--a basis for anterior transposition?

The clinical results of anterior transposition of the ulnar nerve in compressive ulnar neuropathy have been unsatisfactory. This study aims at qualifying and quantifying the vascular anatomy of the ulnar nerve at the elbow so as to enable us to appreciate the possible effects of anterior transposition of the ulnar nerve. In our study of 16 cadaveric limbs, we found that the average number of nutrient vessels supplying the ulnar nerve is 14.3. The main contributing vessel in the arm is the superior ulnar collateral artery, at the elbow, the inferior ulnar collateral artery proximally, and the posterior ulnar recurrent artery distally. In the forearm, the main supply is from the ulnar artery. The average length of the nutrient vessels ranges from 1 cm at the elbow to about 2.6 cm in the arm. The nutrient vessels at the elbow are short, small and numerous. Blood supply to the nerve is segmental in nature. In our histological study of the nerve at the elbow, we found that overall, there are more vascular channels in the intrinsic system than the extrinsic system (statistical significance p < 0.01). From this study, we were able to postulate that there is devascularisation of the ulnar nerve following an anterior transposition. The significance of the devascularisation will require further studies.


Results of total hip replacement in renal transplant recipients.

A vascular necrosis of the femoral head associated with steroid immunosuppression is a cause of significant morbidity in renal transplant recipients. We review the results of 30 total hip replacements in 20 renal transplant recipients with a mean follow-up of 6.3 years. The mean age at the time of surgery was 35 years. The average Hospital for Special Surgery Hip Score was 17 points before operation and 32 points after operation. Fourteen hips were rated excellent and 12 hips rated good. There were four failures--one hip was revised for symptomatic loosening and three prosthesis were removed for infection. Twenty-seven of the hip replacements were subjectively rated as satisfactory by the patient. There was no significant difference in post-operative hip scores between cemented and uncemented prostheses. Total hip replacement in renal transplant recipients in this study has shown good long term result with a revision rate of about 3%. Late infection was a major problem with an incidence of 13%. Prophylactic antibiotics must be used whenever there is a risk of haematogenous seeding from transient bacteremia in these immunosuppressed patients. Use of uncemented prosthesis may make future revision arthroplasty easier.


Tracheo-oesophageal groove clearance in well differentiated thyroid carcinoma.

Papillary carcinoma of the thyroid has a propensity for spread to the regional lymph nodes, in particular those along the recurrent laryngeal nerve. Twenty cases of papillary carcinoma of the thyroid had prophylactic clearance of the lymph nodes along the tracheo-oesophageal groove, and one patient had removal of recurrent disease in the groove. Eleven of the twenty patients had, in addition, some form of cervical lymph node clearance for clinically palpable ipsilateral cervical lymph nodes. Metastases to the tracheo-oesophageal groove lymph nodes was seen in seven of the twenty patients (35%). Tumour size, age, sex, race and cervical lymph node involvement did not appear to predict involvement of the tracheo-oesophageal groove lymph nodes. Clearance of the lymph nodes along the tracheo-oesophageal groove at the time of resection of primary disease is worthwhile for thyroid papillary carcinoma, because of the high incidence rate (35%) and also clearance for subsequent recurrence will be more difficult with a higher risk of damage to the recurrent laryngeal nerve and parathyroids.


A successful peritoneovenous shunting of ascites using the great saphenous vein.

For the surgical palliation of massive ascites, a LeVeen or Denver shunt may be implanted to drain ascitic fluid from the peritoneal cavity into the circulation. But all commercial shunts are costly and depend on a synthetic valve to prevent blood refluxing into the peritoneal cavity. We report here the first patient with a malignant ascites that was successfully palliated by peritoneovenous shunting using the great saphenous vein as a biological valve.


An assessment of preoxygenation techniques using the pulse oximeter.

The effect of preoxygenation with varying inspired oxygen concentration on the arterial oxygen saturation during induction of anaesthesia and intubation was studied using the pulse oximeter. Sixty-five healthy, young adults, (American Society of Anaesthesiologists Class I) undergoing elective surgery were randomly divided into three groups. Group I patients were not preoxygenated. Groups II and III patients were preoxygenated with 50% oxygen and nitrous oxide and 100% oxygen respectively for one minute. All were then induced with thiopentone, paralysed with suxamethonium and orally intubated. During intubation, severe arterial desaturation occurred in those patients who were not preoxygenated (lowest saturation was 81.7 +/- 7.8% occurring 87 +/- 24.5 seconds after suxamethonium injection). This was significantly lower than the other two groups (p < 0.001). No patient had clinical signs of hypoxaemia. Patients who were preoxygenated with either 50% oxygen and nitrous oxide or 100% oxygen showed similar and clinically insignificant desaturation during this period. One minute after intubation and manual ventilation with 100% oxygen, the saturations of all patients returned to preinduction levels.


The aetiopathogenesis of craniofacial anomalies.

Craniofacial embryogenesis with emphasis on the mechanisms of morphogenesis as a basis for understanding developmental anomalies is reviewed. A classification of maldevelopment into malformation, deformation and disruption is illustrated by examples. A brief review of the clinical consequences of craniofacial anomalies and possible therapeutic modalities is undertaken.


Sexual dysfunction in the male end stage renal disease patient.

This article reviews the anatomy and physiology of the male reproductive system and pathophysiology attributed to chronic renal disease. Clinical evaluation strategies are outlined and treatment modalities explained. The role of the nephrology nurse is outlined as a patient advocate and advisor.


Microwave warming of peritoneal dialysis fluid.

A nursing research study was undertaken to determine whether biochemical composition of peritoneal dialysate fluid was altered with microwave heating and whether the external bag temperature of the heated dialysate was a reliable reflection of the actual fluid temperature. No significant laboratory changes were found in the control, heated, or superheated solutions. By closely following established time frames for specific bag solution volume, agitation of fluid prior to instillation, and external temperature check with specific minimum and maximum acceptable temperatures, peritoneal dialysate can be microwaved and used safely.


Clinical experience with erythropoietin in continuous ambulatory peritoneal dialysis.

The purpose of this project was to determine a safe and effective Epogen (EPO) subcutaneous administration schedule for patients who were on continuous ambulatory peritoneal dialysis. To comply with the manufacturer's recommendation to enter a vial only once, a dosing regimen had to be established that used a standard dose of 2,000 or 4,000 units. The goal was to determine the frequency of administration that would achieve and maintain the target hematocrit. Twenty-six patients participated. The starting dose of 4,000 units was administered either two or three times per week. An average 8.3% point increase in hematocrit was seen in 8 weeks. When the target hematocrit of 33% to 35% was reached, the dose and or frequency of administration was decreased. Maintenance doses were established at 2,000 or 4,000 units weekly or biweekly. We were able to meet and maintain the target hematocrit by using 2,000 or 4,000 units per dose and adjusting the frequency.


Work stress, burnout, and sense of coherence among dialysis nurses.

The overall goal of this study was to examine the relationship among work stressors, burnout, and sense of coherence (SOC) in dialysis nurses. Two hundred thirty-eight registered nurses from 56 dialysis units completed a demographic data form, the Nursing Stress Scale, the Maslach Burnout Inventory, and Antonovsky's Sense of Coherence Scale. The results indicated that work load was the major contributing factor to both overall stress and burnout. Understanding the stressors that affect responses to the work environment will allow for successful interventions to alter the risk of exhaustion and burnout.


Bartter's syndrome: a chronic electrolyte losing syndrome.

Bartter's Syndrome is a chronic electrolyte losing syndrome with symptoms and abnormalities that form an organized framework in which to study clinical effects of chronic electrolyte disturbances. Bartter's Syndrome has received minimal attention in continuing education journals. The purpose of this article is to define Bartter's Syndrome, present the historical significance, pathophysiology and clinical signs and symptoms. Selected results of a case study, with specific clearance studies and nursing implications, designed to diagnose and treat this rare renal tubular dysfunction will also be presented.