Pulmonary artery sling.

Eighteen patients who underwent surgical treatment of pulmonary artery sling at this institution since 1969 were reviewed. Four of them had associated tracheal stenoses produced by complete cartilaginous rings (stovepipe trachea). All patients underwent operation. The median age at operation was 180 days (range, 27 days to 54 months). In the 14 patients with isolated pulmonary sling, the operation consisted of division of left pulmonary artery and reimplantation into the main pulmonary artery anterior to the trachea. In the 4 patients with stovepipe trachea, the stenotic tracheal segment was resected on cardiopulmonary bypass and the left pulmonary artery was brought anterior to the trachea before the latter was reanastomosed to the main pulmonary artery. There were no early deaths. One patient died late. The pulmonary artery anastomosis was patent in all 14 patients investigated postoperatively. Three patients have residual tracheobronchial problems. One patient is mentally retarded and is institutionalized. All other patients are symptom-free and growing normally and have normal chest radiographs.


Pulmonary artery sling with tracheal stenosis: primary one-stage repair in infancy.

Pulmonary artery sling is often associated with tracheal stenosis. In many cases repair of the vascular anomaly alone does not relieve dyspnea. Primary one-stage repair with long segment tracheal resection (2.4 cm) and relocation of the left pulmonary artery using cardiopulmonary bypass and deep hypothermic circulatory arrest is described in a 6.5-month-old girl weighing 6.5 kg. This technique resulted in normal ventilation and pulmonary flow distribution.


True aneurysm of the saphenous vein graft stump associated with CABG in a cardiac transplant patient.

Aneurysm of a saphenous vein graft after coronary artery bypass requires surgical resection because of its potential for rupture. This report describes a case of aneurysm formation in a 55-year-old man who underwent coronary artery bypass operation in 1977 and orthotopic heart transplantation 7 years later. A proximal vein graft remnant that had been ligated at the time of transplantation developed into a 5-cm aneurysm. In patients who have undergone previous coronary artery bypass operation, we recommend that the entire vein graft stump be excised and oversewn at the aortosaphenous anastomosis at the time of transplantation.


Chronic, traumatic pseudoaneurysm of the ascending aorta.

Rupture of the ascending aorta is lethal in virtually all cases. In the recent literature, fewer than 9 cases of chronic, traumatic pseudoaneurysm of the ascending aorta have been documented. Reported herein is such a case, discovered incidentally and repaired successfully under cardiopulmonary bypass using a graft prosthesis. Aortogram remains the diagnostic method of choice in these patients.


Aneurysm of the ascending aorta after cardiac transplantation.

We report the case of a 57-year-old female cardiac transplant patient in whom an aneurysm of the recipient side of the ascending aorta developed 1 year after transplantation. Although a mycotic origin was the likely cause, histologic examination diagnosed an atherosclerotic aneurysm.


Simplified correction of outflow obstruction after mitral valve replacement.

Left ventricular outflow tract obstruction after mitral valve replacement may occur when a retained native anterior leaflet prolapses between prosthetic struts. Existing reports of left ventricular outflow tract obstruction by this mechanism lack emphasis on its surgical treatment. We obtained definitive relief of left ventricular outflow tract obstruction by transaortic exposure, division, and partial excision of the obstructing leaflet. This approach minimizes the complexity and potential morbidity of the correction.


Total correction of transposition of great arteries with atrioventricular septal defect.

A successful anatomical correction of transposition of the great arteries with an atrioventricular septal defect is reported. This combination of anomalies is rare, and the anatomical correction is unusual in that the operation involves all four heart valves.


New surgical technique for total-defect aortopulmonary window.

A new technique is described to repair aortopulmonary window with total defect in an 8-day-old baby. Because we expected the future growth of aorta, we used the anterior wall of the pulmonary artery as a large flap to reconstruct the posterolateral aortic wall. An equine pericardial patch was used to repair the defect in the pulmonary artery. This is a logically effective method for aortic reconstruction in a neonate with a large aortopulmonary septal defect.


Newly developed holder for a right-angled metal venous cannula.

A newly developed holder for a right-angled metal venous cannula was developed to make direct insertion into each cava easier, especially insertion into the superior vena cava in pediatric open heart operations. We have been using this holder with ease and safety in all cases of small babies.


Modified urinary collecting bags for prolonged underwater chest drainage.

We describe a method by which a modified urinary collecting bag is used as part of a chest drainage system. This system is especially suitable for patients who require prolonged periods of drainage.


Clarence Crafoord and the first successful resection of a cardiac myxoma.

In 1954 Clarence Crafoord, the pioneer Swedish cardiovascular surgeon, removed an intraatrial myxoma for the first time. The patient was a 40-year-old woman with atypical symptoms of mitral stenosis. Follow-up 38 years later finds the patient alive and well. This case represents not only the first extirpation of a cardiac tumor on cardiopulmonary support but also the dawn of open cardiac surgery in Sweden. Others were soon to follow the lead of Crafoord and his team. However, their bold efforts prepared the way for the early diagnosis and facile extirpation of cardiac myxomas. Moreover, this group played an integral part in the development of safe, effective cardiopulmonary perfusion.


[Consumption of amino acids by Escherichia coli--a producer of recombinant proteins].

The dynamics of amino acid consumption from the medium by Escherichia coli 1864, a strain producing recombinant protein was studied. It was shown that the strain actively used glutamate and aspartate from the medium, which was determined by the leading role of the amino acids in nitrogen metabolism. The strain also consumed threonine, glycine and alanine capable of effectively providing the culture with metabolic energy.


[Isolation of protoplasts of Xanthomonas rubrilineans and their use in the study of localization of aminopeptidases].

The culture of Xanthomonas rubrilineans was able to synthesize a number of intracellular aminopeptidases. To study localization of the enzymes in the cells, a protoplasting procedure was developed providing the yield of 99.7 per cent. The following subcellular fractions were isolated: periplasmic, cytoplasmic and membranous. It was shown that alanine aminopeptidase was a cytoplasmic enzyme and glutamate peptidase was a membrane-bound enzyme.


[Relation between the morphogenesis of Xanthomonas rubrilineans and biosynthesis of aminopeptidase in the process of growth and development of its producer].

The dynamics of growth and development of Xanthomonas rubrilineans, a culture producing intracellular aminopeptidase, was studied. A difference between the growth rate determined by intensity of the total biomass accumulation and the rate of the culture multiplication was found. The difference was due to the presence of two phases in the culture development during the exponential growth: the phase of increasing the linear sizes of the cells and the phase of the culture intensive multiplication. The most intensive synthesis of aminopeptidase was observed during the phase of increasing the linear sizes of the cells. The dynamics of consumption of the main sources of carbon and nitrogen by the culture was investigated.


[Use of analogs of primary metabolites in the selection of the producer of polymyxin B].

A number of amino acids were found to have effects on the growth of the polymyxin B-producing culture and biosynthesis of the antibiotic by it. Of special importance was the stimulating effect by methionine. Four selection stages were carried out with using structural analogs of purines and amino acids as selective factors. There were no stable variants with increased antibiotic productivity among the mutants resistant to the analogs of purines and leucine. The levels of polymyxin B accumulation by the variants resistant to 4-fluorophenylalanine were 30 to 50 per cent higher than those in the controls and the variants were characterized by low morphological and antibiotic production variation in the subcultures. The mechanisms of the methionine physiological effect and the prospects of using analogs of the primary metabolites in improvement of the culture producing polymyxin B are discussed.


[Incorporation of an antineoplastic drug aclarubicin into liposomes in relation to the conditions of its encapsulation].

The results of liposome drug encapsulation of aclarubicin (aclacinomycin A), an antitumor antibiotic, are presented. The method of flow detergent dialysis was applied. Conditions providing maximum encapsulation of aclarubicin (the ratio of lipid components and the lipid/detergent ratio), as well as conditions providing stability of liposomal emulsion (the presence of antioxidants, stearic acid and cholesterol) were defined.


[Amikacin resistance of clinical strains of Enterobacteriaceae and Pseudomonas].

Amikacin resistance was studied in 380 bacterial strains of Enterobacter, Klebsiella, Serratia, Pseudomonas and E. coli isolated in clinics of the Moscow Region. It was shown that 69 isolates were resistant to amikacin. Plasmid DNA was detected in 10 amikacin resistant isolates. Three of them belonging to Klebsiella and 3 belonging to E. coli contained plasmids controlling resistance to amikacin. The plasmids isolated from the strains of Klebsiella determined as well resistance to kanamycin and streptomycin but did not control resistance to sisomicin, tobramycin and gentamicin while the plasmids isolated from the strains of E. coli determined resistance to amikacin, kanamycin, gentamicin, tobramycin and sisomicin.


[Pleiotropic nature of mutation of resistance to 2,3,5-triphenyl- tetrazolium chloride of Francisella tularensis].

Natural strains of F. tularensis were characterized by sensitivity to 2,3,5-triphenyl tetrazolium chloride (TTC). Development of TTC resistance in the cells of F. tularensis was accompanied by changes in the biological properties of the culture, i.e. the colony morphology, antigenic structure, virulence and immunogenicity for laboratory animals. Moreover, there was a direct correlation between the levels of TTC resistance and resistance to chloramphenicol, erythromycin, tetracycline, furazolidone and rifampicin. The antibiotic resistant mutants of F. tularensis were in turn more resistant to TTC than the initial strains. This could be useful in isolation of polymarked strains of F. tularensis for genetic studies and investigation of the nature of the phenomenon of virulence in F. tularensis.


[Comparison of therapeutic effects of antibiotics of the tetracycline group in the treatment of anthrax caused by a strain inheriting tet-gene of plasmid pBC16].

In vivo and in vitro efficacy of tetracyclines was studied with respect to anthracic infection induced by a tetracycline-resistant resistant strain containing plasmid pBC16. The plasmid-containing strain was resistant to tetracycline, doxycycline and minocycline, the MICs exceeding those for the initial strain 500, 640 and 80 times, respectively. There was no therapeutic effect of tetracycline and doxycycline in the treatment and urgent prophylaxis of anthracic infection caused by the tetracycline-resistant strain of Bacillus anthracis. High therapeutic efficacy of minocycline in the average therapeutic concentrations was shown irrespective of the contaminating doses and strains. Minocycline was recommended for treatment and urgent prophylaxis of anthracic infection caused by tetracycline-resistant B. anthracis strains.


[Clinical pharmacokinetics of kanamycin in endolymphatic therapy of peritonitis].

The pharmacokinetics of kanamycin in patients with peritonitis was studied after its intramuscular, endolymphatic and lymphotropic administration. Endolymphatic administration of kanamycin provided an increase in its activity in the inflamed tissues of the peritoneum and omentum and markedly prolonged its halflife as compared to those after the routine intramuscular administration of the drug. Lymphotropic administration of kanamycin failed to provide the same effect. Endolymphatic therapy of the patients during the postoperative period provided a decrease in the lethality, development of complications and the terms of the treatment in the hospital. The therapeutic effect of the endolymphatic administration of kanamycin to the patients with peritonitis proved to be high. The more efficient antibiotic therapy of the cases was likely due to favourable shifts in the pharmacokinetics of kanamycin after its endolymphatic administration.


[Antibiotic therapy in acute diffuse peritonitis].

The pharmacokinetics and clinical efficacy of antibiotics administered by various routes in acute diffuse peritonitis were studied on 25 non-inbred dogs and potential of lymphotropic administration of the antibiotics through the mesentery of the small intestine in urgent surgical operations because of the diseases of the abdominal cavity was estimated. It was shown that the intra-mesenteric administration of the antibiotics was more efficient. In acute diffuse peritonitis it provided high therapeutic concentrations of gentamicin in the central lymph and lymph nodes of the abdominal cavity.


[Immunologic correction with immunoglobulin of toxemia with exicosis in infants with acute intestinal infections].

The clinical course of acute intestinal infections complicated by toxicosis and exicosis was studied in 150 infants undergoing multimodality therapy, including natural human immunoglobulin for intravenous injections. The use of the new complex in the treatment of intestinal toxicoses was accompanied by increasing host immunological reactivity within short periods and decreasing of the treatment duration by 5.0 +/- 1.3 days; there were no persisting and chronic forms of the diseases and fatal outcomes. It was concluded that the use of the immunoglobulin for intravenous injections in the multimodality therapy of intestinal toxicoses in infants made it possible to prevent death in complicated intestinal infections and at the same time to accelerate their recovery.


[A cassette micromethod of determining the sensitivity of anaerobic microorganisms to antimicrobial drugs].

A micromethod based on the use of plates with wells and microquantities of microbial suspensions is described. It provides determination of MICs of antibacterial drugs and sensitivity of clinical strains of anaerobes of 2 or 3 species predominating in pathological materials as well as to preliminarily identify some anaerobic bacteria by their antibiotic sensitivity.


[Elaboration of a rapid method of determining the sensitivity of Brucella to antibiotics].

Optimal conditions were developed for determination of antibiotic sensitivity in Brucella by using enzyme immunoassay directly in the primary cultures of the material tested. The Brucella concentration in the material tested should be not lower than 1.10(6) microbial cells/ml and the time of culture incubation be 24 hours at 37 degrees C. The obligatory condition is to use a liquid medium, i.e. the Albimi broth with 1% glucose. To inhibit the foreign microflora it is recommended to use polymyxin B and amphoglucamine in a concentration of 3 microgram/ml. The use of enzyme immunoassay was shown that it was possible to determine the antibiotic sensitivity of Brucella in practice.


[Effect of doxycycline on leukocyte adhesion in a multifactorial experiment].

The multifactorial analysis was applied to study the effect of doxycycline on leukocyte adhesion to a plastic within wide ranges of the values of experimental factors such as doxycycline concentrations and magnesium and calcium ions. The data were computer-processed and second-order equations characterizing the influence of the factors on adhesion were derived. It was shown that the effect of the ions on adhesion was non-single-valued; accurate quantitative models describing the ion effect on adhesion were developed when the concentration of doxycycline was changed.


[Biochemical indicators of anthracycline sensitivity of blast cells from patients with hemoblastoses].

It was shown that accumulation of adriamycin (ADR) and its impact on DNA synthesis in the blast cells of patients with hemoblastosis studied under conditions of short-term incubation correlated with the antileukemic activity of anthracyclines. The combination of the two biochemical and pharmacological indices, i.e. the high levels of ADR accumulation and inhibition of DNA synthesis, is may useful in solving the problem on inclusion of the antibiotics to the schemes of combined chemotherapy of patients with hemoblastosis.


[Use of Hoechst fluorescent probe 33258 for quantitative analysis of intracellular binding of anthracycline antibiotics to DNA].

The paper deals with development of a procedure for quantitative determination of the share of anthracycline antibiotics bound in cells directly to DNA. A DNA-specific Hoechst fluorescence dye 33258 was used for the purpose. The level of its quenching on DNA correlated with the quantity of the antibiotic bound to it. It was shown that the quenching of the Hoechst fluorescence dye bound to DNA was not due to the dye competition with the antibiotic for the site of bounding on DNA, as was suggested earlier. It was likely to be defined by reabsorption of the radiation by antibiotic molecules.


[Effect of doxycycline on immune response in a multifactorial experiment].

Multifactorial analysis was applied to studies on the effect of doxycycline on the primary immune response to sheep erythrocytes. The experimental factors were the following: the antibiotic dose, the antigen dose and the time of the onset of the antibiotic therapy with respect to the antigen action. Polynomial statistic models describing the delayed hypersensitivity and antibody titers within wide ranges of factor values were designed by the experimental data. It was shown that the prophylactic use of doxycycline prior to the antigenic stimulus markedly lowered the high-dose tolerance induced by high doses of the antigen.


[Antibiotics of the aminoglycoside group (gentamicin, sisomicin and amikacin) in the prevention and treatment of experimental plague].

Activity of aminoglycosides such as gentamicin, sisomicin and amikacin against plague microbe strains of natural origin was studied in vitro. It was also studied in prophylaxis and treatment of experimental plague infection in albino mice. The MAC of gentamicin and sisomicin for 50 strains of the plague microbe was 0.2-1.6 micrograms/ml. For the majority of the strains it was 0.4 micrograms/ml. The amikacin MICs were 0.4-3.2 and 0.8 micrograms/ml, respectively. High efficacy of gentamicin, sisomicin and amikacin was shown in prophylaxis and treatment of experimental plague infection in albino mice. The optimal doses of the antibiotics were determined. Under definite conditions such as the use of short-term regimens and higher intervals, advantages of sisomicin over gentamicin and amikacin in prophylaxis of experimental plague infection were observed.


[Late effects of damaging action of doxorubicin on the reproductive system and progeny of rats].

The effect of doxorubicin, an anthracycline antibiotic, on the reproductive system and progeny was studied in rats 1 month after a single administration of the drug in the MID of 6.85 mg/kg. It was shown that doxorubicin induced a decrease in the number of the mature oocytes in the rat ovary and an increase in the pre- and post-implantation death rate. The rats exposed to the antibiotic 1 month before the mating with intact male rats had unchanged fertility and pregnancy. In the fetuses isolated from the female rats treated with the antibiotic, development of some parts of the skeleton appeared to be retarded. One fetus and one young rat had severe developmental anomalies in the skeletons: shorter right anterior and hind extremities and finger aplasia. The survival rate of the progeny from the female rats exposed to the antibiotic was markedly decreased. No retardation in the physical development of the progeny was observed.


[Prevention of early inflammatory complications after transthoracic interventions and estimation of the degree of immunologic deficiency].

An analysis of the results of the examination and treatment of 379 patients undergoing transthoracic interventions showed that the use of the target-aimed selective immunomodulation, short-term antibacterial prophylaxis, inhibitors of arachidonic acid metabolites, active elimination of the circulating immune complexes and medium-weight molecular peptides and adequate local analgesia after the interventions providing normalization of the laryngeal reflex and early activation of the patients permitted the incidence of the pulmonary complications to be decreased by 2.5 times, pleural complications by 1.7 times, suppuration of the postoperative wound by 1.8 times and the total expenses by 25.6 per cent.


[Lymphotropic antibiotic therapy of obstetrical suppurative-septic diseases].

The pharmacokinetics and efficacy of gentamicin after its direct and indirect endolymphatic administration were comparatively studied. It was shown that the time course of the blood pharmacokinetics of the antibiotic was almost the same as under the both conditions. Therefore, in many cases the less complicated and more available indirect endolymphatic therapy may replace the direct labor-consuming and traumatic endolymphatic administration of drugs.


[Ways of increasing the effectiveness of chemotherapy of urinary tract infection].

Efficacy of blood UV irradiation (BUVI) followed by its reinfusion to the patient in combination with antibacterial therapy was studied in patients with acute and chronic pyelonephritis and its purulent septic complications. The BUVI was used when the antibacterial drugs failed to be sufficiently efficient and the clinical process of the infection was severe. The kinetics of ferritin, transferrin, alpha 2-macroglobulin, beta 2-microglobulin and haptoglobulin in the blood serum was investigated as a criterion of treatment efficacy. It was shown that the BUVI markedly increased the chemotherapy efficacy. The observed regularities of the changes in the serum antigenic spectrum can be used as a basis for the control of treatment efficacy.


[Ofloxacin and ciprofloxacin in the treatment of sexually-transmitted diseases].

A complex clinico-laboratory++ examination and treatment were made of 76 women with inflammatory processes in the urogenital tract. Gonorrhea, trichomoniasis, chlamydiosis and Ureaplasma infection were detected in 60, 31.4, 41 and 14 per cent of the cases, respectively. There were affections of the rectum by gonococci, chlamydia, ureaplasmas and Trichomonas in 55, 32, 10.6 and 6.6 per cent of the cases, respectively. The frequency of chlamydia in the oropharynx amounted to 30 per cent whereas gonococci and ureaplasma were less frequent i.e. 9 and 1.2 per cent, respectively. The combination of the above pathogens in the rectum were the following: gonococci and chlamydia (15 per cent of the cases), gonococci, chlamydia and Trichomonas (7.3 per cent), gonococci and ureaplasma (7.3 per cent), ureaplasma and chlamydia (7.8 per cent). In the throat the association of gonococci and chlamydia was detected in 3.7 per cent of the cases. It should be indicated that the signs of sex-transmitted diseases were few, which required careful clinico-laboratory examination of the extragenital foci in the patients with inflammatory urogenital diseases. Ofloxacin showed a high efficacy in the treatment of patients with gonorrhea and ureaplasmosis. Its use in treatment of chlamydiosis proved inexpedient while ciprofloxacin was effective in the treatment of the infection.


[Use of vilozen and ketotifen combination for increasing the effectiveness and prevention of complications of antibiotic therapy of streptococcal infections].

The clinical efficacy of a vilozen and ketotifen (zaditen) combination in the treatment of streptococcal infections along with the routine therapy was studied. The use of the combination was shown advisable in the complex therapy and prevention of relapses in patients with streptococcal infections. The combined pharmacotherapy promoted better clinical indices, normalization of the immune status and a reduction in the incidence of allergic reactions to antibiotics and a decrease in sensitization to bacterial allergens.


[Plasmid analysis of cadmium- and penicillin-resistant strains of staphylococci isolated in maternity hospitals].

The plasmid analysis of a collection of the staphylococci isolated was made in the obstetric hospitals of Nizhny Novgorod and Arzamas in 1986-1989. It revealed the presence of large complex plasmids with a molecular weight of 22 MD carrying the determinants of resistance to penicillins and cadmium and mercury ions in polyresistant strains. Conjugation transfer of the plasmid even between the staphylococci of different species was performed under experimental conditions. It was suggested that occurrence of the strains carrying the complex cadmium-penicillinase plasmid was due to violation of the sanitary or ecological requirements.


[Antibiotic resistance of Lactobacillus strains].

One hundred and thirty six Lactobacillus strains isolated from poultry and 23 Lactobacillus strains isolated from long-living persons were tested for their antibiotic sensitivity. Occurrence of some type determinants of resistance to aminoglycoside antibiotics and tetracyclines in the Lactobacillus strains resistant to these antibiotics was studied. The majority of the strains from the both collections were resistant to aminoglycosides (73 and 79 per cent, respectively). The isolates from the poultry were characterized by multiple resistance. The isolates from the long-living persons were most frequently resistant to one of two antibiotics. All the tested Lactobacillus strains isolated from the long-living persons were sensitive to tetracyclines. The species composition of the isolates was different. The antibiotic-resistant strains were detected in all the species involved in the study. By hybridization of Lactobacillus colonies with the probes containing various genes of the resistance it was shown that in 14 per cent of the antibiotic-resistant strains belonging to Lactobacillus the antibiotic resistance was controlled by the genes homologous to resistance genes widely distributed in gramnegative organisms. This indicated a possible wide exchange and heterologous expression of the antibiotic resistance determinants between microorganisms of various taxonomic groups.


[Immunomodulating action of heteropolysaccharides isolated from camomile flowers].

Administration of heteropolysaccharides from the camomile flower clusters to rats which failed to perform a physical load (swimming) resulted in stimulation of development of the immune response to SRBCs. However, it did not influence development of the immune response to a bacterial lipopolysaccharide in the rats. A short-term exposure of the swimming animals to high doses of the heteropolysaccharides increased development of the immune response induced by their lipopolysaccharide. A long-term exposure of the swimming rats to low doses of the heteropolysaccharides increased development of the immune response to SRBCs and the lipopolysaccharide. The high doses of the heteropolysaccharides induced excretion of the helper factors by the spleen cells not adhesive to glass while the low doses of the heteropolysaccharides decreased sensitivity of the cells of the immune system to the influence of the suppressing factor excreted by the glass-adherent spleen cells from swimming rats.


[Characteristics of chemotherapy of infectious diseases associated with gunshot wounds and trauma].

The experience in treating infectious diseases in wounded and traumatized persons from the contingent of the Soviet Troops in ++Afghanistan is described. The syndrome of the joint effect of the injury and infection is characterized. Features of the chemotherapy of the injured patients with viral hepatitis, malaria, typhoid fever and enteric and ++extra-enteric amebiasis under the ecological and professional stress and with an account of the etiology of the wound infection are presented. The favourable effect of the developed methods for chemotherapy of the joint affections was shown.


[Rational chemotherapy of suppurative cholangitis].

A complex bacteriological approach to the problem of purulent cholangitis was applied. Specimens of bile from 140 patients, gallbladder walls from 106 patients, liver tissue from 93 patients and peritoneum tissue from 82 patients were examined. It was microbiologically shown that the infectious process in the patients with purulent cholangitis involved not only the bile and gallbladder walls but also the surrounding tissues of the liver and peritoneum. There was a correlation between the bile microflora and the microflora of the surrounding tissues. The microflora of the bile, gallbladder walls, liver and peritoneum tissues was characterized qualitatively and quantitatively. Sensitivity of 494 clinical isolates to 16 antimicrobial drugs was assayed. To prevent the postoperative complications, schemes for the antibacterial therapy were developed with an account of the aerobic and anaerobic spectra of the microbes disseminating the bile, gallbladder walls, liver and peritoneum.


[Effect of indirect endolymphatic antibiotic therapy on clinical and immunological indicators in patients with erysipelas of the lower extremities].

Two groups of patients with erysipelas of the lower extremities underwent indirect endolymphatic therapy with bicillin-3 (58 patients) and routine penicillin therapy (79 patients). Comparative clinicoimmunological examinations in the two groups revealed that lymphotropic administration of the antibiotic had a more favourable effect on the disease process, as evidenced by more rapid reverse time courses of erysipelas clinical signs, less frequent incidence of early relapses and normalization of the majority of immunological parameters by the end of the treatment. For estimation of the anti-recurrence efficacy of the antibiotic therapy in the patients with erysipelas, it was recommended to use a specific scale based on the principles of the Wald successive alternative analysis.


[Age-related characteristics of ceftazidime pharmacokinetics in children].

To reveal possible age-dependent variations in the ceftazidime pharmacokinetics, the drug plasma concentrations were determined by HPLC in 10 children aged 2 to 13 years with peritonitis. The blood specimens were collected 0.25, 0.5, 1, 3, 6 and 8 hours after intravenous bolus administration of ceftazidime (Kefadym, Eli Lilly) in a single dose of 20 mg/kg. The mean values of the model-independent parameters were: total clearance (Cl), 3.3 +/- 0.8 ml/min.kg; steady-state distribution volume, 0.32 +/- 0.06 ml/kg; mean residence time, 1.7 +/- 0.4 hours. The C-coordinate of the gravity center was equal to 26 +/- 7 mg/l. A noticeable age-dependent decrease in Cl was detected by comparing the Cl estimates in our study for the children aged 7.0 +/- 3.0 years with earlier findings in children aged 12 years as well as in adults (18 and 26 years) and elderly patients (77 years): 2.5, 2.2, 2.0 and 1.1 ml/min.kg, respectively. A similar trend was observed for the ceftazidime volume of distribution (Varea). Due to the described reduction in Cl and Varea the age-induced changes in the half-life of ceftazidime were negligible. The age-dependent differences in ceftazidime pharmacokinetics should be taken into account in designing rational dosage regimens for the drug administration.


[Chemotherapy of Campylobacter infections].

A total of 600 patients with suspected alimentary food poisoning were hospitalized. The ++clinico-laboratory findings showed that 27 (4.5 per cent) of them had Campylobacter infection. The cultures of Campylobacter jejuni and Campylobacter coli were isolated from 24 and 3 patients, respectively. The patients underwent complex pathogenetic treatment with oral rehydration saline solutions, symptomatic agents, enzymatic preparations and diet (the basic therapy) supplemented with biological bacterial preparations in less severe cases (8 patients). Antibacterial drugs such as furazolidone (roxytromycin), gentamicin and levomycetin, as well as fluoroquinolones such as ofloxacin and ciprofloxacin were additionally used in the treatment of both the patients with the generalized infection and those with more severe processes of the disease, pronounced diarrhea with blood traces and persisting isolation of Campylobacter (12 patients). The most favourable results in the treatment of more severe patients with Campylobacter infection were obtained with the fluoroquinolones used after inadequately efficient therapy with furazolidone or antibiotics especially in the cases with repeated isolation of campylobacteria.


[Physiological characteristics of the strains of Cryptococcus deffluens--producers of penicillin acylase].

A fermentation medium balanced by the main components was developed for Cryptococcus diffluens strains producing penicillin-V-acylases (PA). It was shown that the culture needed for production of the enzyme was inductor, which was phenoxyacetic acid (POAA). Additional introduction of ethanol to the medium provided an increase in production of PA by 36 per cent and the culture growth by 25 per cent. Introduction of one of the following substances to the medium with POAA and ethanol i.e. (CN3COO)2Ca, FeSO4, proline or asparagine provided an additional increase in the production level of PA by 24 to 94 per cent. The use of the medium varieties will permit one to isolate highly productive cells of the culture.


[Corrected transposition of the great arteries].

Sixty-nine patients with Corrected Transposition of the Great Arteries were studied, with a mean age of 8.3 years. Forty-nine had atrial situs solitus (SS) and 20 atrial situs inversus (SI). The diagnosis was proved by echocardiography in 28 cases and in all by angiocardiography. In cases with SS, 29 presented ventricular septal defect (VSD), 20 had subvalvular pulmonary stenosis (SVPS), 13 tricuspid regurgitation (TR), 13 atrio-ventricular block (AVB), and seven without associated defects. In cases with SI, 13 had VSD, 14 SVPS, five IT, three AVB, and two without associated defects. The long-term follow-up of the atrioventricular (AV) conduction in 53 cases, ranging between 2 and 37 years (mean 8.3) showed at the beginning of the evaluation 37 cases with normal AV conduction, 14 with first degree AVB, and two with complete AVB. At the end of the follow-up 24 cases had normal AV conduction, 13 first degree, two second degree, four intermittent and 10 complete AVB. The contingency table showed that the possibility of developing changes of the AV conduction was greater in those cases who had an abnormality at the beginning with a relative risk of 2.27 (p = 0.03). Twenty-three cases had SVPS associated with VSD without significant symptoms. During a follow-up ranging from 1 to 20 years (mean 6.5 +/- 5.9), five of these patients were surgically corrected at ages from 6 to 11 years. The remaining cases have had a stable course. At the beginning of the study, 18 cases had TR, and it developed in five more patients during the same follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)


[Effect of lead and cadmium on platelet aggregation].

Two heavy metals, lead and cadmium, are frequently found as pollutants in many systems. Their effect upon platelet aggregation was investigated, both in human and rat platelet rich plasma and washed platelets. ADP-induced aggregation of human platelets was inhibited by 50%, using concentrations of free lead between 2-4 mM and free cadmium between 0.05 and 0.2 mM. Rat platelets were about ten times more sensitive to the effect of lead than human PRP. 50% inhibition of epinephrine-induced aggregation was attained at lower concentrations of metal, than the concentrations needed for ADP-induced aggregation. The effect was more apparent upon the first phase, which was lengthened, both with PRP and washed platelets. The aggregation of human and rat washed platelets by calcium was inhibited by concentrations of the metals within micromolar ranges. When A 23187 was used as the aggregating agent, the inhibition by the metals was only partial. Cysteine, at approximately tenfold concentrations, reversed the effect of the metals. Cadmium appeared more effective than lead as an inhibitor of platelet aggregation in all systems. Since only high levels of metal inhibit aggregation, more sensitive organs or systems would show alterations, due to these metals at an earlier stage and at lower concentrations.


[Myocardial hypertrophy in aortic insufficiency as a compensation mechanism. Implications for surgical indication].

We studied 24 patients with pure and severe aortic regurgitation. Using 2-D Echocardiography we obtained parasternal short axis view and calculate the thickness/radio (H/r) ratio and with apical four chambers and two chambers view the ejection fraction (E.F.) with biplanar Simpson technic. The patients were divided in three groups: I) those (12) with E.F. and H/r ratio within normal limits; II) those (6) with low H/r ratio and normal E.F. and the third group III) was formed with 6 patients whom had low H/r ratio and E.F. Three patients from group I had surgical treatment without mortality; all but one (bacterial endocarditis) are alive after two years; five patients from group II had surgical treatment and everyone is alive in functional class I in the same period. All patients of the third group III but one (that had surgical treatment) are death in spite of medical treatment. We conclude that the optimal moment for surgical procedure in severe aortic regurgitation can be determined when the hypertrophy does not compensate the hemodynamic overload (decreases H/r) but the cardiac performance (E.F.) is normal. In this moment the surgical mortality is low and the procedure can change the natural history of the disease.


[Analysis of rheumatic valvulopathy with scanning electron microscopy].

There is a high incidence of rheumatic endocarditis in our environment. Therefore it is important to know the structural characteristics of the valvular lesions in order to better understand the physiopathologic pathways of tissue injury. We have chosen a non-conventional method, the scanning electron microscopy. There were very few such reports in the current literature. We analyzed ten mitral valve with rheumatic scarring lesion and five normal, as a control group. We were able to establish three structural patterns. 1) Stone pavement like (endocardium with nuclear bulge cells and marginal folds at the cell boundaries, abundant number of microvillous projections and few areas of endothelial loosening). 2) Cerebroid (subendothelium with wrinkles caused by deformity of the valve with or without endothelial loosening) and 3) Smooth pattern (flattened endothelium with scanty microvillous projections and abundant areas of endothelial denundation and exposition of subendothelium). More damage was noted in the auricular surface of the rheumatic group, characterized by a predominance of the smooth pattern. We found Lambl's excrecences in two mitral leaflets, they were formed by collagen break fascicles of the subendothelium. This technique allowed us to analyze integrity of the endocardial selective barrier and the interactions between the damaged surface of the valve and elements of the peripheral blood and showed more endocardial injury in the rheumatic group. These alterations could play an important role in the pathogenesis of this disease.


[Ruptured aneurysm of the aortic sinus of Valsalva: clinical course, diagnosis, and treatment].

The authors present the clinical cases of 5 patients, with rupture of the aortic Valsalva's sinus aneurysm open to the right chambers, diagnosed clinically, echocardiographically and hemodynamically in the past eight months. Among them, four were males, and one female. Three were treated surgically successfully, one patient refused surgery and another had a sudden death before surgery. The patients showed arteriovenous blood flow shunt, three from the aorta to the right ventricle, and two to the right atrium. One case was associated to an atrial septal defect, and tricuspid insufficiency in another. The authors added a sixth case: a woman, with rupture of the aortic Valsalva's sinus open to the right ventricle, aortic insufficiency and diaphragmatic subaortic stenosis. The authors discuss the embryologic origin of the formation and rupture of the Valsalva's sinus aneurysm as well as the factors that contribute to it's rupture, the natural history of the illness, it's classification, association with other heart disease as well as diagnosis and treatment.


[Late results of mitral valve replacement in 155 subjects under 16 years of age. Comparative study with 4 prosthesis].

We followed 155 children aged 6 to 16 years who underwent mitral valve replacement for rheumatic heart disease. Group I included 74 patients with Starr-Edwards prostheses and the mean follow-up period was 13 years. Group II was formed by 36 patients with Bjork-Shiley prostheses and a mean follow-up of 7.5 years. Group III consisted of 31 children with dura mater bioprostheses and a mean follow-up of 5.1 years. Finally, group IV included 14 patients followed a mean period of 4.9 years with Hancock xenografts. The four groups of patients were comparable before surgery. The criteria of the New York Heart Association (NYHA) were used to evaluate all patients before and 12 months after surgery. All patients with mechanical prostheses received anticoagulant therapy with acenocumarol from the first postoperative day. The incidence of complications such as thromboembolism, infective endocarditis, prosthetic dysfunction and death were determined at the end of the follow-up. The Fisher's exact test was used for nonparametric analysis and the two-tailed Student's T test for parametric results. All but two patients improved their NYHA clinical status after surgery (p less than 0.0001). Forty eight patients with mechanical prostheses were catheterized 1 to 7 years after the operation. The mean pulmonary arterial systolic pressure was reduced from 58 mmHg to 30 mmHg (p less than 0.001) and the mean pulmonary arterial wedge pressure decreased from 22 mmHg to 11 mmHg (p less than 0.001). There were no significant differences between the groups with mechanical and tissue prostheses in the incidence of thromboembolism and infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)


[Percutaneous transluminal angioplasty in aortic coarctation in adolescents and adults. Mid-term results].

From October 1985 to February 1992 we performed 80 percutaneous transluminal angioplasty (PTA) in 76 patients with coarctation of the aorta (CoAo). Sixteen of them with ages ranging from 12 to 62 years (mean = 21.1). We describe the experience in these cases. Fifteen with native and one with post-surgical coarctation. The gradient decreased from 72 +/- 33 to 18 +/- 17 mmHg immediately after dilation, in the follow-up (1 to 69 months m = 25) was 23 +/- 20 mmHg. In one patient we performed simultaneously angioplasty of CoAo and mitral valvuloplasty with excellent results in both lesions. We redilated two cases for residual gradient successfully. We had one failure in a patient with long coarctation. He needed surgery. In the initial experience we had one severe complication (cerebral stroke). No deaths or aneurysms. In conclusion we believe that PTA is an adequate alternative in adolescents and adults with native or post-surgical coarctation of the aorta with minimum incidence of complications.


[Recessive autosomal inheritance in Marfan syndrome].

Three brothers 9, 12, and 14 years of age were studied. The three of them fulfilled the diagnostic criteria of Marfan Syndrome that was made based on physical and ophthalmologic examination, these criteria included musculoskeletal abnormalities, subluxation of lens, myopia and aortic aneurysm. The three siblings died due to complications of the aortic aneurysm, which had an early onset as well as the other clinical manifestations of the disease. They were 2 brothers and one sister. There was neither mental or psychomotor retardation, nor metabolic disease in any of the patients. Family history did not show any clinical manifestation of the disease in parents or grandparents. We propose that the hereditary pattern is recessive autosomic instead of dominant autosomic given the features of these cases and their history.


Influence of extracellular calcium on the actions of guanidine at the rat neuromuscular junction.

Guanidine has been shown to potentiate neurotransmission at the skeletal neuromuscular junction. The present study was undertaken to evaluate whether reductions in extracellular calcium affect the action of guanidine on the reversal of neuromuscular blockade induced by dibekacin and d-tubocurarine in the rat phrenic-hemidiaphragm preparation. Guanidine reversed the blocking effect of d-tubocurarine, the maximal effect occurring with 3 mM at 15 min. This reversal effect of guanidine was potentiated when the extracellular calcium concentration was reduced from 2.5 mM to 1 mM and 0.3 mM. Guanidine was also effective in reversing the neuromuscular depression caused by dibekacin. In this case, it was more potent than in the d-tubocurarine-treated preparations. The maximal effect was observed with 3 mM after 15 min of exposure. When the extracellular calcium concentration was reduced from 2.5 mM to 1 mM, a potentiation of guanidine effects was observed. In this situation, the maximal effect of guanidine was observed with only 0.7 mM. However, further reductions of extracellular calcium (0.3 mM) did not show further increases. The present results show that guanidine reverses the blockade induced by dibekacin and d-tubocurarine, being more potent against the former drug. This suggests that guanidine may be useful in relieving the blockade due to a restriction of calcium entry. Its effects were potentiated when the extracellular calcium concentration was lowered to 1 mM and, in d-tubocurarine-treated muscles, to 0.3 mM. Thus, the effects of guanidine are calcium-dependent but only in a certain concentration range.


[Doppler echocardiography assessment of tricuspid valve prosthesis with normal function and with dysfunction due to obstruction].

In order to know the normal ranges of the maximum velocity and the pressure half-time between normal functioning tricuspid prostheses and malfunctioning tricuspid prostheses due to obstruction, we studied 25 patients with tricuspid prostheses (11 mechanical and 14 biological); they were divided in 2 groups: group I: 14 patients without clinical evidence of malfunction and; group II: 11 patients with malfunction due to obstruction confirmed by catheterization, surgery and/or necropsy. The peak gradient was estimated by the modified Bernoulli equation and the prosthetic valve area by the pressure halftime method. the mean peak velocity in group I was 147 +/- 18 cm/sec versus 165 +/- 16 cm/sec (p NS) in group II. The mean pressure half-time in group I was 124 +/- 20 msec versus 355 +/- 48 msec (p less than 0.001) in group II. 1. A pressure half-time greater than 200 msec is very suggestive of malfunction due to obstruction (p less than 0.001). 2. There are normo-functioning tricuspid prostheses with prolonged pressure half-time, and the values that divides these groups from those with malfunction is small: 199 and 244 msec, that is why we suggest that every patient has to have his her own echocardiographic control in the immediate postoperative period.


Effects of bifemelane hydrochloride on loss of N-methyl-D-aspartate receptor and muscarinic cholinergic receptor binding in the gerbil hippocampus after transient ischemia.

The effects of bifemelane hydrochloride on changes of N-methyl-D-aspartate receptors and muscarinic cholinergic receptors were examined in the gerbil hippocampus after transient ischemia with radioactive-specific ligands. There were marked reductions in both these receptors in the gerbil hippocampus 14 days after transient ischemia, without changes in the respective affinities. Post-ischemia bifemelane treatment almost completely prevented the ischemia-induced decreases in the numbers of these receptors, and had no effect in sham-operated controls. The results of the present study suggest that this drug prevents postsynaptic dysfunction induced by transient ischemia, and may be useful in the therapy of both the chronic and the acute stage of cerebrovascular disease.


St-93 hyperglycemia in Wistar rats.

The alpha 2-adrenoceptor agonist St-93 was evaluated for its effect on blood glucose levels in Wistar rats. A dose-dependent increase in blood glucose was observed in rats after intraperitoneal administration of St-93. The hyperglycemic effect of St-93 was not altered by prazosin and propranolol, whereas idazoxan significantly inhibited this effect. Pretreatment with reserpine did not affect the hyperglycemic effect of St-93. There was no significant increase in the blood glucose values with St-93 in streptozotocin-diabetic rats. It may be concluded that the hyperglycemia induced by St-93 is mediated through alpha 2-adrenoceptors, possibly located on pancreatic beta-cells.


Influence of long-term lithium treatment on 5-hydroxytryptamine-mediated stimulation of adenylate cyclase in guinea-pig hippocampus.

The effects of long-term lithium treatment on the 5-hydroxytryptamine-mediated stimulation of adenylate cyclase activity in guinea-pig hippocampal membranes were examined. The stimulatory effect of 5-hydroxytryptamine on adenylate cyclase activity was guanine nucleotide-dependent and additive to those of dopamine, isoproterenol, norepinephrine, epinephrine and histamine. In contrast, the adenylate cyclase activity stimulated by 10 microM of 5-hydroxytryptamine plus 10 microM of 8-OH-DPAT was quite equal to that stimulated by 10 microM of 5-hydroxytryptamine alone. Oral administration of lithium for 3 weeks reduced, slightly but significantly, the concentration-response curve to 5-hydroxytryptamine but did not alter that to 8-OH-DPAT. Inhibition of the forskolin-stimulated adenylate cyclase activity by 5-hydroxytryptamine or 8-OH-DPAT was shown to be unaltered after lithium treatment. The implications of these results are discussed with reference to previously reported data using hippocampal membranes prepared from rats.


Reduction by carbachol of ventricular conduction impairments induced by various class I antiarrhythmic drugs in anesthetized dogs.

A common property of all Class I antiarrhythmic agents is the inhibition of the fast inward current INa. Consequently, ventricular conduction velocities are impaired and reentrant phenomena are counteracted. Unfortunately, these conductive pathway disturbances may also induce proarrhythmic effects and reduce cardiac contractility. Recent evidence indicates that a cholinergic agonist, carbachol, is able to correct in vitro both the duration of the action potential and the partial depolarization induced by lidocaine and quinidine in rabbit atria. In the present study, we demonstrated that i.v. carbachol is also a powerful agent in vivo for correcting conductive disturbances previously induced by four different Class I antiarrhythmic agents. The electrophysiological and hemodynamic parameters of ten groups of atropinized-anesthetized dogs, including six animals per group, were investigated. QRS duration, HV and V-St intervals were selected as in vivo indexes of ventricular conduction. Quinidine, procainamide, cibenzoline and flecainide were selected as representative agents of Class Ia and Ic antiarrhythmic drugs. In all treated groups, carbachol (1 mg/kg) was able to correct the indexes of ventricular conduction previously impaired by the antiarrhythmic drug used.


Activation of capsaicin-sensitive primary afferents in the rat urinary bladder by compound 48/80: a direct action on sensory nerves?

We have assessed the ability of compound 48/80, a mast cell degranulating agent, to activate the sensory and efferent function of capsaicin-sensitive primary afferents in the rat urinary bladder. Compound 48/80 produced a calcium-dependent release of calcitonin gene-related peptide-like immunoreactivity from the superfused rat urinary bladder. This effect was prevented by in vitro capsaicin desensitization, but was not affected by indomethacin, methysergide, ondansetron, chlorpheniramine or cimetidine, nor by systemic pretreatment with compound 48/80 at a dose regimen which prevented lethality produced by intravenous administration of it in anesthetized rats. Compound 48/80 also produced a contraction of the rat isolated bladder which was not reduced by methysergide, indomethacin or in vitro capsaicin desensitization. In vivo, topical application of compound 48/80 on the serosal surface of the rat urinary bladder activated a series of high amplitude rhythmic bladder contractions which were hexamethonium-sensitive (micturition reflex). This effect was prevented by systemic capsaicin desensitization while it was unchanged by chlorpheniramine, methysergide, indomethacin or ondansetron. Administered intravenously, compound 48/80 produced a plasma protein extravasation (Evans blue leakage technique) in the rat urinary bladder which was abolished by systemic capsaicin pretreatment or chlorpheniramine while it was unaffected by methysergide or indomethacin. The present findings provide direct neurochemical evidence that compound 48/80 activates the peripheral endings of capsaicin-sensitive primary afferent neurons, leading to a stimulation of their sensory and efferent functions in the rat urinary bladder. The possibility of a direct action of compound 48/80 in producing excitation of capsaicin-sensitive sensory nerves should be considered.


Inferior vena cava filters. Indications, safety, effectiveness.

Preventing pulmonary embolization by interrupting vena caval flow has been attempted since 1893. Inferior vena cava (IVC) filters have been available for 20 years, and currently there are five filters commercially available in the United States (Greenfield filter, Titanium Greenfield filter, Simon-Nitinol filter, Bird's Nest filter, and LGM or Vena Tech filter) and two other filters under development (Amplatz filter and Günther filter). Although these devices are widely used, their clinical utility and safety have not been completely evaluated. Controlled clinical trials to determine the clinical role for IVC filters have not been attempted, but numerous case series describing the outcomes of the seven current filters have been published. We have systematically reviewed these studies to clarify what is known about the indications, safety, and effectiveness of IVC filters. Using the MEDLINE database, all English-language publications since 1970 that included follow-up clinical information after filter insertion were reviewed and eight methodologic guidelines were employed to assess the scientific quality of the clinical information. Twenty-four case series were reviewed: 16 concerned the Greenfield filter (1632 patients), and eight dealt with newer designs (925 patients). Commonly noted methodologic problems included failure to report the initial extent of thromboembolic disease, incomplete description of the patient assembly process, and incomplete and potentially biased outcome assessment. Recurrent clinical pulmonary embolism was rare after filter placement, and only eight deaths from pulmonary embolism were reported. Filter complications were common but rarely life threatening; four (0.16%) deaths from filter complications were noted among the reviewed studies. Thrombotic complications following filter placement included insertion-site deep vein thrombosis and IVC obstruction. These events were rare, but they occurred with all filter types. Inferior vena cava filters appear to be effective in preventing recurrent pulmonary embolism. Despite the large published experience with IVC filters, many questions remain about their indications, safety, and effectiveness. Anticoagulant therapy, if not contraindicated, should be used in conjunction with filters. While there is no ideal filter, some situations call for specific filters. Filter selection and insertion require experience, modern angiographic technique, and collaboration between clinicians caring for patients and the interventional radiologists or surgeons inserting the device.


Vasodilatory activity of etozoline in rat and guinea-pig isolated aorta: study of the mechanism of action.

In isolated rings of guinea-pig aorta not responding to acetylcholine, the diuretic etozoline did not influence basal vascular tone but inhibited noradrenaline- and histamine-induced contractions. The inhibition was evident at concentrations of the diuretic (10 microM-1 mM) suitable to inhibit, in a competitive manner, the contractions evoked by a K+ channel blocker, tetraethylammonium, in the same preparation (Dorigo et al., 1989, 1990). In isolated rings of guinea-pig aorta, etozoline, at very low concentrations (1 nM-0.1 microM), inhibited also serotinin-induced contractions. The contractile effect of serotonin was abolished by nifedipine associated with 2-nitro-4-carboxyphenyl N,N-diphenyl-carbamate (an inhibitor of phospholipase C) or with etozoline, thus suggesting that the diuretic, besides inhibiting extracellular Ca++ uptake, also prevents intracellular Ca++ mobilization mediated by inositol triphosphate. In isolated rings of rat aorta responding to acetylcholine, etozoline did not influence basal vascular tone either in the absence or in the presence of superoxide-dismutase. In the same preparation, the diuretic inhibited vascular contractions induced by the three spasmogenic agents used, i.e. noradrenaline, histamine and serotonin. This inhibition occurred at concentrations of etozoline ranging from 10 microM to 1 mM and was uninfluenced by indomethacin (10 microMs). In isolated rings of rat aorta, the contractile effect of noradrenaline was not influenced by the addition of either 100 microM pyrogallol, or 10 microM methylene blue or 100 U/ml superoxide-dismutase, while the contractile responses to histamine and to serotonin were potentiated by pyrogallol and by methylene blue and reduced by superoxide-dismutase. This indicates that, in rat aorta, noradrenaline evokes only a direct contractile response, whereas both serotonin and histamine have a double effect: direct contraction of vascular smooth muscle and release of a relaxing factor from the endothelium. The inhibitory activity of etozoline towards serotonin- and histamine-induced contractions was reduced by pyrogallol and by methylene blue, whereas it was potentiated by superoxide-dismutase. The ability of etozoline to reverse the noradrenaline-induced contraction was unaffected by pyrogallol, methylene blue or superoxide-dismutase. These results emphasize the spasmolytic activity of etozoline, which seems to involve only the muscular component of rat and guinea-pig aorta.


Effects of chronic administration of lisuride hydrogen maleate on aromatic amine and metabolite levels in the gerbil brain following bilateral common carotid ligation.

Cerebral monoaminergic neurotransmitters and their metabolites show various concentration changes in gerbils following bilateral carotid ligation. The present study evaluated the effect of chronic administrations of lisuride hydrogen maleate (lisuride) on these changes. Lisuride (0.01 mg/kg or 0.05 mg/kg) or vehicle was intraperitoneally administered to gerbils for 14 consecutive days before the induction of a 30 min ischemia by bilateral carotid ligation. Animals were sacrified immediately and the levels of dopamine, DOPAC, homovanillic acid, noradrenaline, serotonin and 5-hydroxyindoleacetic acid determined by HPLC in the striatum, cortex, hippocampus and diencephalon/midbrain. Lisuride itself had no effect on any compound determined in any region. In the carotid-ligated gerbil brain, however, lisuride corrected the reduction of dopamine in the striatum, normalized or reduced increases in the (DOPAC+homovanillic acid)/dopamine ratio in the striatum, hippocampus and diencephalon/midbrain, and increased the levels of serotonin in all four regions. The present study, together with previous reports, indicate that lisuride may interfere with ischemia-induced cerebrovascular disturbances and, in such a way, improve some pathological sequelae of cerebrovascular disease.


Cost-conscious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis. A review and suggestions.

Salicylates and nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of painful disorders. This article reviews the efficacy, side effects, and costs of these agents and proposes a practical approach to using them in a cost-effective manner. Although there may be some differences in efficacy among available drugs, these do not appear sufficient to justify using the more expensive agents in most cases. Adverse effects, especially gastrointestinal (GI), add to the cost of using these drugs. Aspirin and all nonsalicylate NSAIDs share a risk of causing gastric ulcer, upper GI bleeding, and GI perforation. Prostaglandin inhibition by these agents may lead to reduced glomerular filtration rate and renal failure. There may be modest differences in GI and renal risks with the different agents, but these are minimal. Prophylaxis against gastric ulceration with anti-ulcer drugs has been recommended, and one agent, misoprostol, is approved for use in the United States for this purpose. Whether use of prophylaxis will increase or decrease the costs associated with NSAID therapy remains to be determined. Nonacetylated salicylates may cause less GI adverse effects and may be somewhat "renal sparing." Strategies that would reduce the cost of care for painful musculoskeletal disorders without compromising quality of care include using acetaminophen instead of an NSAID for noninflammatory disorders, trying nonacetylated salicylates as less expensive and safer alternatives to NSAIDs, using one agent at a time, allowing sufficient time to evaluate the therapeutic effect before changing agents, returning to the least expensive and/or safest drug if a trial of several in succession fails to find one that is clearly better, and reserving prophylactic use of antiulcer agents for patients who are at especially high risk and for whom anti-inflammatory effects are clearly needed.


Pneumocystis prophylaxis and survival in patients with advanced human immunodeficiency virus infection treated with zidovudine. The Zidovudine Epidemiology Group.

Pneumocystis carinii pneumonia (PCP) is a major cause of morbidity and mortality in persons with advanced human immunodeficiency virus (HIV) infection. We assessed the impact of prophylaxis for PCP on survival in patients with advanced HIV disease who were treated with zidovudine. A cohort of 1048 patients with prior PCP (N = 437), another acquired immunodeficiency syndrome-defining diagnosis (N = 168) or acquired immunodeficiency syndrome-related complex (N = 443) and with less than 0.250 x 10(9)/L CD4 cells initiated zidovudine treatment between April 1987 and April 1988. They were then followed up for 24 months. Morbidity and mortality outcomes were assessed every 2 months. A time-dependent, Cox proportional hazards model was used to identify factors associated with new episodes of PCP and with survival. Three hundred thirty-six patients (32%) developed PCP after beginning treatment with zidovudine, with a 24-month actuarial rate of 41%. Patients with prior PCP were more likely to develop PCP during follow up (40%) than those without a history of PCP at entry (27% with PCP at follow-up). Other factors associated with developing PCP were baseline acquired immunodeficiency syndrome vs acquired immunodeficiency syndrome-related complex, and dose interruptions of zidovudine. Thirty-six (17%) of 210 patients who received trimethoprim-sulfamethoxazole prophylaxis developed PCP vs 299 (36%) of 838 who never received trimethoprim-sulfamethoxazole (odds ratio, 0.48). One hundred seven (22%) of 483 patients who ever received aerosol pentamidine prophylaxis developed PCP vs 228 (40%) of 565 who did not receive aerosol pentamidine (odds ratio, 0.55). In a time-dependent Cox proportional hazards analysis, trimethoprim-sulfamethoxazole (relative hazard, 0.21; 95% confidence interval [CI], 0.11 to 0.4) and aerosol pentamidine prophylaxis (relative hazard, 0.25; 95% CI, 0.16 to 0.39) were associated with decreased risk of PCP. Pneumocystis carinii pneumonia during follow-up was strongly associated with death when controlling for other factors (odds ratio, 1.8). For all patients, aerosol pentamidine prophylaxis was associated with a reduced risk of death during follow-up (relative hazard, 0.59; 95% CI, 0.44 to 0.78), while trimethoprim-sulfamethoxazole showed a weaker association (relative hazard, 0.74; 95% CI, 0.54 to 1.1). However, there was a significantly reduced risk of death overall for patients who consistently used trimethoprim-sulfamethoxazole (relative hazard, 0.55; 95% CI, 0.35 to 0.88) or aerosol pentamidine (relative hazard, 0.57; 95% CI, 0.42 to 0.77) and this was most pronounced in patients with a baseline history of PCP. Pneumocystis carinii pneumonia was common in advanced HIV infection treated with zidovudine. Prophylaxis with trimethoprim-sulfamethoxazole and aerosol pentamidine both were associated with a decreased likelihood of PCP, and consistent use of each was associated with improved survival. Prophylaxis for PCP is associated with prolonged survival for patients with advanced HIV disease.


Stroke complicating acute myocardial infarction. A meta-analysis of risk modification by anticoagulation and thrombolytic therapy.

The objective of this meta-analysis was to examine the impact of systemic anticoagulation and thrombolysis on the total incidence of stroke following myocardial infarction. Additionally, we sought to compare the relative risk of stroke with different thrombolytic agents. A computerized and manual literature search for controlled clinical trials of anticoagulants and thrombolytic agents in myocardial infarction reporting on total strokes in treated and control patients was used. Pooling was performed by calculating the Mantel-Haenszel odds ratio and 95% confidence interval (CI). The Mantel-Haenszel pooled odds ratio for anticoagulation trials was 0.46 (95% CI, 0.30 to 0.64), suggesting a benefit of anticoagulant therapy. However, a statistically significant degree of variability (heterogeneity) was present among study results. The odds ratios for all thrombolytic trials, tissue plasminogen activator, and streptokinase trials, respectively, were 1.08 (95% CI, 0.87 to 1.35), 1.28 (95% CI, 0.76 to 2.17), and 1.02 (95% CI, 0.80 to 1.30), suggesting no overall excess of stroke with thrombolysis. The pooled odds ratio for three studies directly comparing streptokinase and tissue plasminogen activator was 0.73 (95% CI, 0.61 to 0.86), suggesting an excess of stroke for patients treated with tissue plasminogen activator in comparison with streptokinase-treated patients. The available data may support a role for anticoagulants in reducing the incidence of stroke after myocardial infarction, but the heterogeneity among the trials makes interpretation of this effect difficult. Although the available data do not indicate an increase in stroke with thrombolysis, a direct comparison of tissue plasminogen activator and streptokinase reveals an excess of strokes with tissue plasminogen activator.


A national survey of the home visiting practice and attitudes of family physicians and internists.

Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.


Asthma management preceding an emergency department visit.

The burden of illness from asthma in North America has not decreased despite advancements in understanding disease pathogenesis and improved pharmacotherapeutics. This study examined the adequacy of preventive measures applied to asthma. Using a standardized self-administered questionnaire, 111 consecutive patients presenting to the emergency department because of asthma were surveyed about their "usual" level of disability from asthma, usual medications, self-management plans to deal with an asthma attack, and environmental control measures. Twenty-five percent of subjects suffered sleep disturbance more than 15 days per month, had work/school attendance affected more than 14 days per year, and previously visited an emergency department twice in the past year. Thirty-seven percent had no effective plans to deal with an attack and another 32% had plans that were never discussed with a physician. Although 78% reported that cigarette smoke aggravated their asthma, one third of these were exposed at home. For a significant proportion of adults requiring emergency health services for asthma, preexisting management was poor by current standards. We recommend that patients be screened by emergency physicians and those with identifiable inadequacies in usual care be referred to physicians with expertise in asthma management.


Low survival rate after cardiopulmonary resuscitation in a county hospital.

The standard of practice in hospitals in the United States is to perform cardiopulmonary resuscitation on all patients who suffer a cardiac arrest unless a specific order has been written to the contrary. In recent decades, however, data showing a low rate of survival to discharge under certain conditions have accumulated, leading some to question this policy. The objective of this study was to examine variables predictive of patient survival following cardiopulmonary resuscitation using standardized methods of measuring severity of illness. All patients were identified who underwent cardiopulmonary resuscitation on the medicine service at Los Angeles County (California) Hospital from August 15, 1990, to February 15, 1991. Severity of illness was evaluated by examining diagnosis, Acute Physiology and Chronic Health Evaluation II score, and organ system failure. Cases were followed up prospectively until death or hospital discharge, and data concerning post-arrest mental status, utilization of resources, and disposition were gathered. Of the 131 patients identified, 22 patients (16.8%) survived for 24 hours but died before discharge; only four patients (3.1%) survived to discharge. This study suggests that in some settings (eg, institutions that are for sick patients under conditions where monitoring is limited because of scarcity of resources), survival after full cardiopulmonary arrest may be even lower than previously documented.


Travel and ciguatera fish poisoning.

Ciguatera fish poisoning is a distinctive clinical syndrome associated with the consumption of contaminated marine fish. It is endemic in many popular travel destinations, including the Caribbean and Pacific Islands, where travelers are at risk. Clinical review of 23 patients (60% were travelers) with ciguatera fish poisoning in whom consultation was provided between 1987 and 1990. Seven patients acquired ciguatera fish poisoning during international travel to the following destinations: Bahamas (n = 4), Dominican Republic (n = 1), British Virgin Islands (n = 1), and United States (n = 1). Suspected fish included grouper, red snapper, and amberjack. Two patients required emergency care, and four patients developed chronic symptoms. Severity was associated with chronicity, duration of peak symptoms, and worsening of symptoms with sexual activity. Chronicity was associated with severity, long latency period, and duration of peak symptoms. The three patients with complete resolution were scuba divers. Amitriptyline was the drug most often providing benefit for chronic symptoms. Ciguatera fish poisoning is a health risk to travelers to endemic regions, and their risk likely equals that of indigenous population groups. Barracuda should never be eaten, and travelers should exercise caution when considering other fish dishes, notably, grouper and red snapper.


Hyperthyroidism as a cause of atrial fibrillation in long-term care.

We measured sensitive thyrotropin-stimulating hormone (sTSH) in 50 consecutive nursing home patients (39 men) with atrial fibrillation to determine the frequency of hyperthyroidism. Patients were identified in a long-term care facility by an electrocardiogram demonstrating atrial fibrillation. The sensitive thyrotropin-stimulating hormone assay had a detection limit of less than or equal to 0.02 mU/L (normal range, 0.46 to 3.60 mU/L). No subject had a suppressed sensitive thyrotropin-stimulating hormone. Hyperthyroidism is not a common cause of atrial fibrillation in male nursing home residents.


Transdermal clonidine reduced some withdrawal symptoms but did not increase smoking cessation.

Clonidine may be useful in controlling tobacco withdrawal and in facilitating smoking cessation. This study was developed to test the efficacy of transdermal clonidine in promoting smoking cessation. We conducted a five-center, double-blind, placebo-controlled, randomized controlled trial of transdermal clonidine in conjunction with a minimal behavioral intervention for smoking cessation. The intervention was based on the American Lung Association's Freedom From Smoking program. Self report of not smoking was validated with exhaled air carbon monoxide of less than 8 ppm and salivary cotinine of less than 20 ng/mL. Transdermal clonidine therapy began 1 week before the target quit date: 0.1 mg/24 h for the first 4 days increasing to 0.2 mg/24 h for the next 3 days, if the lower dose was tolerated. The highest tolerated dose was then continued for 6 weeks after target quit day. Withdrawal symptoms were measured daily for the first 7 days after target quit day. A total of 213 patients were enrolled (106 active drug and 107 placebo). During the study, 15.5% of patients had drug therapy discontinued due to adverse effects, 24.5% (26/106) taking active drug vs 8.4% (9/107) receiving placebo. There was a significant reduction in anxiety score from 3.0 to 2.4 (placebo vs active) and irritability score from 2.2 to 1.7 (placebo vs active) during the first week after cessation. There was no reduction in other withdrawal symptoms. The overall 12-week abstinence rate was 33.0% (35/106) in the active drug group vs 34.5% (37/107) in the placebo group (not significant). This study demonstrated some reduction in early withdrawal symptoms with the use of a clonidine transdermal patch, but no increase in cessation rate, 6 weeks after medication had been discontinued.


Iatrogenic complications in high-risk, elderly patients.

This study explores the quality improvement potential of reviewing care for long-stay, elderly medicine service patients hospitalized for congestive heart failure, acute myocardial infarction, or pneumonia at a large Midwestern teaching hospital. Medical records were reviewed for 120 patients aged 65 years or older who were discharged between January 1987 and June 1989, with hospital stays of 15 days or longer. Patients' severity of illness on admission was rated using the Medicare Mortality Predictor System; process quality of care was rated using a structured implicit review form for judging several dimensions of clinical assessment and decision making. Serious complications were coded by etiology and type and judged as possibly or probably preventable. Logistic regression was used to identify risk factors for iatrogenic events; multiple regression was used to assess potential outcome bias in ratings of overall quality of care. Of 120 medical records reviewed, 70 (58.3%) suffered at least one iatrogenic complication. Forty-three patients (35.8%) suffered an iatrogenic complication rated as potentially preventable. Significant predictors of all iatrogenic complications were quality ratings of initial physician assessment, patients' inability to walk unassisted, and low Glasgow Coma Score. For potentially preventable complications, quality ratings for physician documentation of functional status were also significant. Ratings for overall quality of care were not significantly influenced by the mere presence of death or complications. Iatrogenic complications are likely to be an extremely common experience for elderly medicine service patients with long lengths of stay. A significant portion of these complications may be potentially preventable with closer attention to initial assessment and documentation of patients' functional status.


Clinical prognostic factors in lupus nephritis. The importance of hypertension and smoking.

Many previous studies of the influence of sociodemographic and clinical factors on the development of renal failure in patients with lupus nephritis have been based on selected subgroups of patients and have yielded conflicting results. We sought to determine the prognostic importance of patient demographic characteristics (age, gender, race, and socioeconomic status), smoking status, and hypertension in the development of end-stage renal disease (ESRD) among patients with lupus nephritis. This retrospective cohort study followed an inception cohort of 160 adults with lupus nephritis. The outcome measure was the development of ESRD, defined as the institution of maintenance dialysis or measurement of a creatinine clearance of 10 mL/min or less. Life-table analysis was used to determine differences between patient subgroups in the time to development of ESRD. End-stage renal disease developed in 41 (26%) of 160 patients followed up for a median of 6.4 years. Hypertension and smoking status at the onset of nephritis were strongly associated with differences in the time to development of ESRD. The median time to ESRD among patients with moderate to severe hypertension (diastolic blood pressure, greater than or equal to 105 mm Hg) was 7 months, among patients with mild hypertension (diastolic blood pressure, 90 to 104 mm Hg) it was 146 months, and among normotensive patients it was greater than 273 months. The median time to ESRD among smokers was 145 months and among nonsmokers it was greater than 273 months. These effects persisted in multivariable analyses adjusting for differences among patients in age, gender, socioeconomic status, renal histology, and immunosuppressive treatment. The independent effects of hypertension and smoking resulted in shorter times to renal failure among patients who were both hypertensive and smoking, compared with nonsmoking hypertensive patients. The development of ESRD did not differ among patient demographic subgroups. Patient demographic characteristics had no detectable impact on the rate of progression to ESRD in this cohort. Hypertension and smoking appear to be important, potentially modifiable, factors influencing the prognosis of patients with lupus nephritis.


A comparison of two-dimensional echocardiography vs carotid duplex scanning in older patients with cerebral ischemia.

To determine the relative value of two-dimensional (2D) echocardiography vs carotid duplex scanning and to devise an optimal, cost-effective diagnostic approach for older patients with cerebral ischemia, 68 consecutive patients in sinus rhythm who suffered focal cerebral ischemia were studied. All patients underwent 2D echocardiography and carotid duplex scanning in addition to routine clinical evaluation. Twenty-five of 68 patients had Q-wave myocardial infarction by electrocardiography; nine (36%) of these 25 had left ventricular mural thrombi demonstrated by 2D echocardiography. In contrast, none of 43 patients without Q-wave myocardial infarction had clinically unsuspected findings diagnosed by 2D echocardiography. Duplex scanning, however, identified significant, abnormal findings in the carotid artery ipsilateral to the involved cerebral hemisphere in 23 patients (34%). Thus, in older patients in sinus rhythm who suffer a cerebral ischemic event, carotid duplex scanning has a higher diagnostic yield than 2D echocardiography and appears to be a more cost-effective initial test. Our data suggest that in patients with carotid distribution cerebral ischemic events and no obvious cardiac source for emboli by history and physical examination, 2D echocardiography should be limited to those with evidence of Q-wave myocardial infarction by electrocardiography; such management should optimize diagnostic yield and cost effectiveness.


Severity of hepatic encephalopathy before liver transplantation is associated with quality of life after transplantation.

Cirrhosis is associated with a chronic low-grade hepatic encephalopathy and disturbances in quality of life. This study investigated the extent to which severity of hepatic encephalopathy before orthotopic liver transplantation correlated with quality of life. A battery of neuropsychological tests was administered to nonalcoholic patients to quantify severity of hepatic encephalopathy. The Sickness Impact Profile was administered before and after surgery to document quality of life across multiple health and psychosocial dimensions. There was substantial improvement from the pretransplant to the posttransplant periods across almost all dimensions of quality of life. Neuropsychological test scores explained up to 20% of the variance in magnitude of change from pre (before) to post (after) surgery. Severity of hepatic encephalopathy (particularly with respect to static ataxia and fine motor control) is associated with posttransplantation improvement in quality of life.


A prospective study of Staphylococcus aureus nasal colonization and intravenous therapy-related phlebitis.

Intravenous (IV) therapy-associated phlebitis is common, but its causes are ill defined. Some cases may be related to bacterial colonization of the skin surrounding the IV catheter, especially by Staphylococcus aureus. This prospective study examined the association of phlebitis with anterior nares S aureus carriage, as well as with other potential risk factors. Selected demographic and clinical data and a nares culture were collected from patients on designated wards by us and from the IV therapy team at the time of initial IV catheter placement. Patients were followed up for signs and symptoms of phlebitis for the duration of the initial catheter's use and for up to two additional IV placements. Potential risk factors were compared for patients who developed phlebitis and those who did not by the Cox multivariate proportional hazards model. During 10 weeks, 273 men with a total of 416 catheter placements had fully evaluable data. Phlebitis occurred during 13.7% of the catheter placements. Nasal cultures yielded S aureus from 14.3% of the patients, but none of the IV team nurses. Surprisingly, S aureus nasal colonization was related (at borderline statistical significance) to a reduction in phlebitis risk. Location of the patient on a surgical ward, the presence of infection at any site, and a larger-gauge catheter were each significant independent risk factors for phlebitis. The highest risk of phlebitis appeared to have been within 12 to 24 hours of catheter placement. The primary finding of this study was that nasal colonization with S aureus did not increase the risk of developing IV catheter-associated phlebitis. Our rate of IV catheter-associated phlebitis was similar to that in other studies, but the factors predisposing to phlebitis differed somewhat from those in previous studies.


Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness.

To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time. Prospective structured interviews. University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla. One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians. Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia. Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences. The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.


Orthostatic hypotension in ciguatera fish poisoning.

The purpose of this study was to investigate the pathophysiology of persistent orthostatic hypotension in a patient with ciguatera fish poisoning. A patient who became ill and who developed prolonged and symptomatic orthostatic hypotension with ciguatera fish poisoning after eating barracuda is described. Studies of autonomic function included measurements of plasma catecholamine levels in the supine and standing positions, and pressor responses to infusions of norepinephrine, atropine, and propranolol. Volume depletion was excluded as a cause for hypotension. Our patient showed low plasma catecholamine levels and marked pressor hypersensitivity to norepinephrine infusion. Hypotension and bradycardia were reversed by atropine infusion. The heart rate freed from autonomic influences, ie, after atropine plus propranolol infusion, was normal. In ciguatera fish poisoning, orthostatic hypotension appears to be a result of both parasympathetic excess and sympathetic failure.


[Coronary angioplasty of multivessel coronary diseases. Apropos of 1664 procedures. Immediate results and results following 6 months].

Between 1980 and 1990, 1,664 coronary angioplasty procedures were performed in 1,307 patients (86.6% male) with multivessel disease. The average age was 57 +/- 3 years (range 29 to 83 years). There was a previous history of infarction in 40.1% of patients and 22.4% of the procedures were performed for unstable angina. Catheter and 58.2%, 1,220 double vessel and 444 triple vessel diseases. A total of 2,509 lesions were dilated (1.5 stenoses/patient). The primary success rate was 81.9% with 3.2% of infarcts and 3.5% emergency bypass procedures and a global mortality of 2%. The factors responsible for death in the acute and hospital phases were unstable angina, age > 70 years, and ejection fraction < 35%. Complete revascularisation was achieved in 14.3% of cases: the only predictive factor for complete revascularisation on multivariate analysis was double vessel disease. A 6 months clinical and angiographic control was obtained for 83.8% of controllable procedures (965 dilatations). The restenosis rate was 47.9%. Univariate analysis of the factors of restenosis identified clinical parameters (age > 58 years, triple vessel disease, diabetes and unstable angina), parameters related to the lesion (length of stenosis > 1 cm, percentage stenosis > 80%) and to the procedure (residual stenosis > 20%): 68.4% of patients with restenosis underwent repeat angioplasty with a significantly superior primary success rate 88.7% vs 81.9% of global successes (p < 0.001). With a 82% primary success rate with few major complications, coronary angioplasty is a safe and effective therapeutic alternative. The extent of the lesions and the presence of chronic occlusion are the main limitating factors of revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)


[Uncovered bones on the Baltic Sea beach--human or animal?].

Report of an unusual finding of bones on the shore of the Baltic Sea. Although the morphological findings appeared similar to a human foot skeleton, a quick identification as sea dog bone was possible.


[Relative value of attenuation and negativation of systolic pulmonary venous flow in severe mitral insufficiency. Transesophageal echocardiographic study].

The aim of this study was to analyse the velocity profile of the systolic fraction of the pulmonary venous flow (PVF) in mitral regurgitation (MR). Three velocity profiles were identified in left superior pulmonary vein. Inversion of the systolic fraction of the PVF was specific for angiographic grade 4 MR (specificity 97%, sensitivity 100%). On the other hand, a decrease in this wave is much less specific for mild MR and depends on severe factors such as left atrial pressure, size and ejection fraction and the lack of atrial systole (as in atrial fibrillation or atrioventricular block). Therefore, inversion of PVF has a good positive predictive value for severe MR, but the interpretation of attenuation of this wave should take into consideration not only the MR but also left atrial pressure and compliance.


[Contamination in illegal amphetamine. Contaminants resulting from the synthesis of 3,4-(methylenedioxy)amphetamine (MDA) via condensation between nitroethane and piperonal].

Some impurities of illegally synthesized 3.4-(methylenedioxy)amphetamine (MDA) are presented. These compounds were detected in laboratory glassware which had been used for the synthesis of MDA via phenyl nitropropene route.


[Value of signal-averaged electrocardiogram in ventricular arrhythmia without apparent heart disease].

Signal-averaged electrocardiography was performed in 132 subjects with various ventricular arrhythmias without clinically apparent heart disease and compared with the results obtained in a series of 45 normal subjects. The latter enabled definition of the following criteria of normality: QRS duration after averaging < 113 ms; Simson vector of the last 40 ms (RMS40) > or = 17 microV; low amplitude signal duration over 40 microV < 38 ms for a high pass bidirectional filter of 40-300 Hz. Complementary investigations (echo or angiography), performed in all cases, showed underlying abnormalities in 26 patients: 13 right ventricular dysplasias, 7 cardiomyopathies, 3 mitral valve prolapses and 3 minor congenital heart defects. These investigations were normal in the remaining 106 subjects. Of the 26 patients with cardiac disease, 15 had 3 criteria of positivity for late ventricular potentials, 6 had 2 criteria and the other 5 had no criteria of late ventricular potentials. Therefore, 81% of cases with cardiac disease had at least 2 diagnostic criteria of late ventricular potentials whereas only 4% of those without cardiac disease, and in the control group, had criteria of positivity (p < 0.001). Using these criteria, the predictive value of signal-averaged electrocardiography for the detection of underlying cardiac disease was good when 2 criteria are required for diagnosis of late ventricular potentials: sensitivity 81%, specificity 96%; predictive value of a positive test 78%, predictive value of a negative test 97%. Signal-averaged electrocardiography is therefore a good non-invasive method of diagnosing underlying cardiac disease in patients with ventricular arrhythmias without clinically apparent heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)


[Left intraventricular gradients measured by Doppler echocardiography at rest, during exercise and during isoproterenol test in hypertrophic cardiomyopathy].

Doppler echocardiography has been shown to be an accurate method of assessing left ventricular outflow obstruction in hypertrophic cardiomyopathy (HCM). One of the characteristics of this pressure gradient is its variability and, therefore, we measured this parameter during dynamic exercise testing in 33 patients. The results were compared with those recorded during isoproterenol infusion, the reference stress test for patients with HCM. Submaximal exercise in the recumbent position is usually well tolerated and resulted in a 43% increase in heart rate and a 47% increase in pressure gradient. There was a significant correlation between resting and exercise outflow obstruction (r = 0.90; p = 0.001). Moreover, exercise echo revealed obstruction in 26% of patients without resting pressure gradients (latent obstruction). The interpretation of results obtained with isoproterenol infusion is more difficult: this test resulted in an important increase in the left ventricular pressure gradient (231%) and "revealed" obstruction in 84% of cases. Therefore, we believe that exercise is more physiological and better tolerated than isoproterenol stress infusion and should be adopted as the investigation of choice in HCM even without obstruction at rest. If it is not possible to perform the exercise or no outflow tract obstruction can be demonstrated, an isoproterenol infusion may be used but this is not always well tolerated and the results should be interpreted with caution.


[Defined contusion marks caused by the knife handle].

If in inflicting a stab wound the knife is vigorously pushed in up to the end of the blade, this does not only cause cutting of the tissue, but also a blunt traumatization. The resulting abrasions can correspond with the respective construction parts (handle, handguard, devices for fixing the open blade) as to position, shape and size, thus allowing conclusions as to the shape of the instrument used. Incomplete, one-sided marks of the handle suggest an oblique-angled stab. The presence of a contusion mark shows that the blade penetrated completely, which makes it easier to draw conclusions as to the length of the blade from the depth of penetration. The reconstruction possibilities are demonstrated on the basis of three autopsies (homicide cases with different types of knives).


[Unusual cases of self-asphyxiation].

Based on the description of the findings of four cases of self-strangulation with multiple knotting of the strangling device examined by the authors general criminological and specific forensic criteria for differential diagnosis of suicide and commission of the offence by another person are discussed. Though multiple knotting of the strangling device, caught hair and parts of clothes and concomitant injuries may also be seen in cases of suicide, they primarily justify the suspicion that the death was caused by another person. If it is one of those rare cases of self-strangulation with multiple knotting, the presence of symptoms of congestion in the head area, which may occasionally be absent in other cases of strangulation, is necessary for pathophysiological reasons.