[Ultrasonic tissue characterization in hypertrophic cardiomyopathy: analysis of three-layered appearance of the ventricular septum by apical approach].

In normal hearts, two-dimensional echocardiography from the apical window displays the left ventricular wall as a three-layered appearance (TLA): central bright layer and bilateral sonolucent zones. The TLA is considered to reflect the normal myocardial architecture: the predominant latitudinal fiber bundles of the midwall layer, and longitudinal or oblique ones on both sides. We analysed the TLA of the ventricular septum in 20 normal subjects, 20 patients with left ventricular hypertrophy due to pressure load (LVH), and 81 patients with hypertrophic cardiomyopathy (HCM). Of the 81 HCM patients, the layering was often obscure or absent in 53 (65%), whereas LVH patients showed clear TLA as well as normal hearts. In patients with severe layering disorder (n = 30), the age at diagnosis was lower (40 +/- 15 vs 50 +/- 12, p less than 0.05), and familial occurrence (53 vs 11%, p less than 0.01) and severe functional limitation (NYHA greater than or equal to III) were more common (27 vs 4%) than in those with clear TLA (n = 28). The disturbed layering detectable by echocardiography may reflect the disorder of basic myocardial fiber architecture in the ventricular septum, and is likely to become a useful marker of the pathologic severity of the disease.


[Electrophysiologic effect of a new Ca(2+)-antagonist, TA-3090 on supraventricular tachycardia and conduction system].

We investigated the effect of a new Ca-antagonist, TA-3090 on supraventricular tachycardia (SVT) and conduction system, comparing it with the effect of Diltiazem Hydrochloride, in 11 patients who had paroxysmal SVT attacks. Seven of the 11 patients presented atrioventricular reentrant tachycardia (AVRT) via retrograde concealed conduction through an accessory pathway, and the others presented AV nodal reentrant tachycardia (AVNRT). After SVT was induced by means of programmed electrical stimulation at high right atrium, TA-3090 (0.1 mg/kg body weight) or Diltiazem (0.2 mg/kg) was administered intravenously for 3 minutes. TA-3090 terminated nine of 11 SVTs, while Diltiazem terminated four of 4 SVTs. On termination of SVT, both drugs interrupted A-H conduction during AVRT and the slow pathway during AVNRT. After TA injection, five of 11 SVTs could not be induced by programmed electrical stimulation, while two of 4 SVTs could not be induced after Diltiazem. In AVRT, three patients in which TA-3090 prevented SVT induction had a longer AV node effective refractory period than that of the others in which TA-3090 could not prevent SVT (330 +/- 46 vs 210 +/- 24 msec, p less than 0.01). However, SVT was induced more easily than before in three of the 11 patients treated with TA-3090 administration, and in one of the 4 patients treated with Diltiazem administration.(ABSTRACT TRUNCATED AT 250 WORDS)


[Augmentation of left ventricular slow filling in hypertrophic cardiomyopathy].

To investigate the significance of augmentation of left ventricular slow filling, trans-mitral flow (TMF) was echocardiographically observed through pulsed Doppler method in 116 patients with hypertrophic cardiomyopathy (HCM), 74 with dilated cardiomyopathy (DCM), 27 with mitral regurgitation (MR), 86 with old myocardial infarction (OMI) and 80 normal controls (C). The slow filling-wave (SFW) in TMF was defined as the filling wave with obvious peak velocity during slow filling phase. The peak velocities (E, A, S) of the early filling, the atrial contraction and the slow filling waves were measured. The SFW was divided into two patterns according to the S and E ratio: large SFW (S/E greater than or equal to 1/2) and small SFW (S/E less than 1/2). 1) The small SFW was more frequently, but not significantly, observed patients with MR (37%) than in normal subjects (18%), patients with HCM (10%), DCM (4%) and OMI (7%). However large SFW was observed in 16 patients (14%) with HCM, but not in normal subjects and patients with other cardiac diseases excluding one patient with DCM. 2) In normal subjects and patients with DCM, OMI and MR, those with small SFW had larger E and smaller A/E than those without small SFW. However in patients with HCM, there was no difference in these indices (E and A/E) according to whether the patients were with or without SFW. 3) In HCM, patients with large SFW had significantly smaller E and significantly larger isovolumic relaxation time than those without SFW. Thus, appearance of the large slow filling wave, which might be caused by abnormal relaxation of the left ventricle, was frequently observed in patients with HCM.


[Long-term follow-up of clinical features and ECG changes in 50 patients with HCM].

We studied the relation of ECG changes during the clinical course in patients with hypertrophic cardiomyopathy (HCM). Fifty patients with HCM were categorized in two groups; 20 patients with, and 30 patients without signs of deterioration of clinical state. The changes between the first and the final ECG were compared in these two groups. The average follow-up period was 7.6 years. Twenty patients with clinical deterioration presented increase in QRS intervals (0.06----0.071 sec, p less than 0.025), decrease in voltage of RV5 (2.81----2.38 sec, p less than 0.025), increase in newly developed abnormal Q waves, and P wave changes. In contrast to these cases, 30 patients without clinical deterioration presented no significant ECG changes. Amplitudes of the negative T wave were unchanged in both groups. We conclude that electrocardiographic observations proved to be useful for predicting clinical features in patients with HCM.


[Clinical value of PMN elastase activity before reperfusion therapy in acute myocardial infarction: comparison with clinical characteristics, reperfusion events and myocardial damage].

Many recent studies demonstrate that neutrophils may be involved in the genesis and propagation of myocardial ischemia and reperfusion injury. Clinical value of PMN elastase activity before reperfusion which is released from activated polymorphonuclear leucocyte were evaluated in 30 patients with acute myocardial infarction. 19 patients with normal or moderately elevated PMN elastase activity (G1: less than 200 micrograms/l) revealed similar clinical characteristics before reperfusion therapy, compared to 11 patients with extremely high PMN elastase activity (Group 1: greater than or equal to 200 micrograms/l). But Group 1 represented fewer incidence of reperfusion events (Group 1 2/19, Group 2 7/11, p less than 0.01) such as arrhythmia, BP down, re-elevation of ST segments, and increased chest pain just after reperfusion, and higher incidence of salvaged myocardium in the risk area (Group 1 5/11, Group 2 4/19 p less than 0.1) evaluated by Tc-99m PYP, T1-201 dual SPECT, than Group 2. Wall motion analysis also showed that both global and regional wall motion were severely depressed in Group 2 compared with Group 1 (Group 1: Global EF 66.6 +/- 13.5, Extent 26.5 +/- 17.4, Severity 63.1 +/- 48.5, Group 2: Global EF 51.2 +/- 10.6, Extent 40.1 +/- 16.3, Severity 112.8 +/- 55.5, p less than 0.01 for Global EF, Extent, and p less than 0.05 for Severity). These data suggest that leucocyte activation before reperfusion may play important role in the genesis of reperfusion injury.


[A case of middle aged women with isolated left coronary ostial stenosis].

A-50-year-old woman was admitted to our hospital for the examination of exertional chest pain. She had no coronary risk factors. No hormonal disorders were observed. Physical and laboratory examinations revealed that she had not suffered from syphilis or aortitis syndrome or any other inflammatory diseases. An exercise electrocardiogram (Master's test) demonstrated ST segment depression in V3-6, II, III and a VF. On coronary angiography, a 75% stenosis of the left coronary ostial stenosis was found, but no abnormality was found in other arterial trees. The patient was diagnosed as having isolated coronary ostial stenosis. She underwent coronary bypass surgery from the aorta to the circumflex artery and the anterior descending coronary artery. She is now completely asymptomatic. A review of the literature together with this patient reveals the following characteristics of patients with isolated coronary ostial stenosis. Firstly, the patients are almost always middle aged woman with no coronary risk factors. Secondly, the involved coronary artery is the left main coronary artery, so its obstruction results in a serious condition. Therefore, though its pathogenesis remains to be determined, isolated left coronary ostial stenosis seems to be a distinct clinical entity.


[A case report of two mitral valve aneurysms with one perforation after two attacks of infective endocarditis].

Aneurysms of the mitral valve complicating infective endocarditis (IE) are uncommon. The patient was a 57-year-old man who was admitted to our hospital for a precise examination of heart failure. One year before, the first two-dimensional echocardiography showed an aneurysm of the anterior mitral leaflet possibly due to a previous attack of IE. Doppler color flow mapping detected a regurgitant jet from the mitral valve aneurysm into the left atrium during systole, which suggested perforation of the aneurysm, and an aortic regurgitant jet flowing against the anterior mitral leaflet. Because the patient's family refused cardiac catheter examination and surgery, we treated him in the out-patient clinic. A few weeks before his admission, he had discontinued taking diuretics because of uncomfortable urinary frequency. He gradually developed the symptoms of heart failure and entered our hospital. IE was suspected because of leucocytosis and slight fever. Two-dimensional echocardiography revealed a new aneurysm of the anterior mitral leaflet without perforation, located in the distal part of the old aneurysm. This time, his family consented to the surgical treatment. Aortic and mitral valve replacement was successfully performed. It was pathologically confirmed that the two mitral aneurysms had been caused by IE.


Effect of hyaluronidase on interstitial pressure response to edema in air-inflated rabbit lung.

The response in perivascular interstitial pressure to water accumulation was measured in air-inflated isolated rabbit lungs. The blood vessels and trachea of isolated lungs were cannulated and the vascular cannulas were connected to a reservoir filled either with a 3% albumin in saline solution (control) or with hyaluronidase in the albumin solution (treated). The lungs were inflated to 5 cmH2O transpulmonary pressure and the vascular reservoir elevated to a height of 7-10 cm above the lung base. The reservoir was suspended by a load cell which measured liquid accumulation in the lung. As the lung gained weight, interstitial pressure was measured by the micropuncture technique in the interstitium surrounding a vein near the hilum of an upper lobe. In control lungs, interstitial pressure increased monotonically with time from a value slightly below 0 cmH2O (pleural pressure) to a value of approx. 3.0 cmH2O by 5 h. In treated lungs, interstitial pressure increased more slowly to a value of approx. 1.5 cmH2O by 5 h. Interstitial compliance, the change in weight gain divided by the change in interstitial pressure, was 1.2 g.(g lobe wt)-1.cmH2O-1 for the control lungs and 2.9 for the treated lungs. A two-compartment electrical analog model representing the perivascular interstitium and alveolar liquid space was developed to simulate the data. The analysis indicated that in the control lungs, perivascular interstitial conductance and compliance were 5-fold and 15-fold smaller than those of the alveolar liquid space, respectively. The slower rise in interstitial pressure with water accumulation in the treated lungs was attributed to an increased compliance of the alveolar liquid space. The effect of hyaluronidase on the alveolar liquid space was to increase its compliance 2.4-fold with little change in its fluid resistance.


Respiratory mechanics of the coatimundi and woodchuck.

The coatimundi breathes with a large tidal volume and relatively short TE/TTOT while the woodchuck has a relatively long TE/TTOT compared to other mammals. Hence, the respiratory mechanics of the coatimundi and woodchuck were studied to determine whether mechanics play any role in the differences in breathing pattern observed in these two mammals of similar body size. Although static respiratory system compliance was less and lower airway resistance was greater in the woodchuck compared to the coati there was no significant difference in deflationary time constant that could contribute to the difference in expiratory time. Both species exhibit less compliant chest walls than would be predicted for animals this size (4.5 and 5 kg) and the coati lung compliance is greater than that of the woodchuck or the prediction. The large tidal volume in the coati may be attributed in part to the large lung volume of this species (2.2 times the allometric prediction). The differences in breathing pattern are more likely related to differences in the control of breathing (i.e. regulation of expiratory airflow and inspiratory onset) than to differences in respiratory mechanics.


Chemosensitivity and breathing pattern regulation of the coatimundi and woodchuck.

An analysis of breathing pattern regulation was carried out on the coatimundi and woodchuck who represent two different volume-time patterns. It was found that the coati, with a short expiratory time as a fraction of total breath time, TE/TTOT, has a greater sensitivity to CO2 as represented by the slope and threshold of its ventilatory response. Breathing air the coati maintains post-inspiratory inspiratory activity (PIIA) of the posterior cricoarytenoid (PCA) through 51% of expiration, while the woodchuck, who is less sensitive to CO2 and has a long TE/TTOT, exhibits no PIIA of the PCA. The woodchuck also has a greater incidence and duration of end-expiratory pauses (or delayed inspiratory onset). The woodchuck does not demonstrate the usual inverse relationship between VT and TE in response to 5% CO2 and does not recruit PIIA of the PCA at this level of CO2. These data confirm the importance of CO2 chemosensitivity in regulation of TE. It is further demonstrated that interspecific differences in chemosensitivity among three mammals of the same size are reflected in regulation of TE but not in inspiratory 'drive' (as indicated by mean inspiratory flow, VT/TI).


High intensity exercise training-induced metabolic alterations in respiratory muscles.

Limited information exists concerning the effects of high intensity interval exercise training (HIET) on metabolic alterations in both inspiratory and expiratory muscles. To test the hypothesis that HIET will improve the oxidative capacity of the diaphragm and major expiratory muscles, we examined Krebs cycle and beta oxidation enzyme activities in the diaphragm and three groups of expiratory (abdominal) muscles in rats subjected to 12 weeks (5 days.wk-1) of treadmill exercise. Two groups of female Sprague-Dawley rats (age ca 120 days) were studied: (1) HIET group (n = 10; animals performed 6 x ca 5-min running intervals.day-1 at ca 90-95% VO2max); (2) sedentary control group (n = 7). When compared to controls, HIET resulted in significantly elevated (P less than 0.05) activities of 3-hydroxy-acyl-Co-A dehydrogenase (HADH) and citrate synthase (CS) in the costal diaphragm, rectus abdominus, external obliques, and the plantaris muscles. In contrast, training did not increase (P greater than 0.05) the activities of CS or HADH in the crural diaphragm or the internal obliques/transversus abdominus muscles. By comparison, the training-induced increases in oxidative capacity (e.g., CS activity) in the costal diaphragm, rectus abdominus, and external obliques were relatively small (ca 23, 10, 12%, respectively) when contrasted to the exercise-induced increase in CS activity in the plantaris muscle (ca 47%). We conclude that HIET results in small but significant improvements in the oxidative and beta oxidation capacities of the costal diaphragm and at least two abdominal expiratory muscles.


Activity of abdominal muscle motoneurons during hypercapnia.

Our purpose was to examine the influence of hypercapnia on the activity of motoneurons innervating the transversus abdominis and internal oblique abdominal muscles, and of integrated phrenic and abdominal motor nerve activities. Studies were done in nine adult cats that were decerebrated, vagotomized, thoracotomized, paralyzed and ventilated mechanically. Of 42 motoneurons examined, 24 showed strong respiratory modulation (RM neurons), with the discharge confined primarily to the central expiratory period. The remaining 18 motoneurons discharged tonically, and failed to show respiratory modulation even at increased levels of central respiratory drive. Hyperoxic hypercapnia augmented the activities of the phrenic and abdominal nerves and increased the early expiratory discharge frequency of the RM neurons. The hypercapnia-induced increase in firing frequency during early expiration was accompanied by a corresponding decline in late expiration, and a virtual abolition of the inspiratory activity in the few neurons that discharged in this phase under normocapnic conditions. Finally, hypercapnia induced an increase in the number of spikes generated during each expiratory period in about half of the RM neurons, whereas the remaining cells showed a decrease. Thus, the increased peak activity of the integrated whole abdominal nerve burst with hypercapnia was brought about by a shift in the temporal pattern of motoneuron firing, or by an increase in the number of spikes generated during the expiratory period. The steep rate of rise and the pronounced early expiratory peak observed in the integrated abdominal nerve burst during hypercapnia in this preparation are consistent with the increase in motoneuron firing frequency during the early stages of the expiratory phase.


Diaphragmatic fiber type specific adaptation to endurance exercise.

Recent evidence suggests that exercise training results in a significant improvement in the oxidative capacity of the mammalian diaphragm; however, limited data exist concerning which diaphragmatic fiber types are metabolically altered due to training. To test the hypothesis that exercise training increases the oxidative capacity of diaphragmatic type I and IIa fibers only, we examined the effects of endurance training on the fiber type specific changes in oxidative capacity, cross-sectional area, and capillarity of the costal diaphragm. Female Fischer-344 rats (age ca 180 days) were divided into either sedentary control group (n = 6) or an exercise training group (n = 6). The trained animals exercised for 10 wks on a motor-driven treadmill (60 min.day-1; 5 days.wk-1) at a work rate equal to ca 55-65% VO2max. Capillaries were identified histologically and fiber types determined using ATPase histochemistry. Fiber cross-sectional area (CSA) and succinate dehydrogenase (SDH) activity in individual fibers were measured using a computerized image analysis system. Compared to control animals, training did not increase the capillary to fiber ratio in any diaphragm fiber type (P greater than 0.05); however, training increased capillary density (capillary No./CSA) in type IIa fibers due to a reduction in cell CSA (P less than 0.05). Further, training resulted in significant (P less than 0.05) increases in total diaphragmatic SDH activity (delta increase = 17.5%) and an increase in SDH activity in both type I (delta increase = 14%) and IIa fibers (delta increase = 17.4%). In contrast, training did not alter (P greater than 0.05) SDH activity in type IIb fibers.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of dopamine on ventilatory response to incremental exercise in man.

We investigated whether dopamine, an inhibitory neuromodulator in the carotid body, would alter the ventilatory response typically associated with metabolic (lactic) acidosis during exercise. Six subjects performed incremental cycle ergometer exercise to exhaustion during infusions of dopamine (3 micrograms.kg-1.min-1) or saline. Ventilation and pulmonary gas exchange were computed breath-by-breath; arterialized venous blood was collected every 90 sec for measurement of lactate, potassium and blood gases. The resting ventilatory response to an isocapnic step decrease in end-tidal PO2 to 50 Torr was used as an index of carotid body drive. Dopamine diminished the hypoxic ventilatory response but had no effect on the ventilatory response during exercise. Peak lactate, potassium, and ventilation were unaffected by dopamine, and the degree of respiratory compensation for the metabolic acidosis was the same as in control experiments. Therefore, either the carotid bodies respond differently to hypoxia than to acute metabolic acidosis and/or hyperkalemia during heavy exercise, or the carotid bodies are not the sole mediators of hyperventilation above the lactate threshold.


Neural respiratory responses to cortically induced seizures in cats.

Seizure activity can lead to profound respiratory stimulation in spontaneously breathing animals with intact respiratory feedback mechanisms (Paydarfar et al., Am. J. Physiol. 260, R934, 1991). The present study was designed to test the hypothesis that peripheral respiratory feedback mechanisms are not important for the genesis of seizure-induced hyperpnea. Studies were performed in 16 anesthetized, vagotomized, glomectomized cats whose end-tidal PCO2 (PETCO2) was kept constant. Integrated phrenic nerve activity was used to represent respiration. Seizures were induced by injection of penicillin into the parietal cortex and electrocorticographic (ECoG) and biceps femoris nerve activities, arterial pressure, airway PCO2 and brain temperature were recorded continuously. Progressive seizure activity was associated with progressive increases of respiratory frequency and peak phrenic activity, despite constancy of PETCO2 and brain temperature. Patterns of entrainment were identified among ECoG spikes, biceps femoris nerve and phrenic nerve activities. Phrenic nerve activity became highly irregular during generalized ictal seizures and ceased to respond to changes of PETCO2. Acute intercollicular decerebration in all experiments resulted in normalization of respiratory rhythm even while ictal ECoG activity continued. We conclude that stimulation of breathing during seizures occurs in the absence of respiratory feedback mechanisms. The findings suggest that an important cause of the respiratory response is a feedforward mechanism, whereby activation of subcortical structures above medulla and pons results in stimulation of breathing.


Angiotensin II potentiates neurally mediated contraction of rabbit airway smooth muscle.

The effect of angiotensin II (AT II) on cholinergic neurotransmission in rabbit tracheal segments was studied under isometric conditions in vitro. AT II concentration-dependently potentiated the contractile response to electrical field stimulation (EFS), and caused a leftward shift of the frequency-response curves for EFS, so that the stimulus frequency required to produce a half-maximal effect (ES50), decreased from 7.0 +/- 0.1 to 3.0 +/- 0.1 Hz (P less than 0.01). In contrast, the contractile response to acetylcholine was not affected. Non-peptide AT II receptor antagonist CV-2961 attenuated the effect of AT II on the EFS-induced contraction. Pretreatment of tissues with thiorphan or phosphoramidon did not alter the action of AT II. Thus, AT II may prejunctionally potentiate the neurally-mediated contraction of airway smooth muscle through activation of AT II receptors on the cholinergic nerve terminals, and this effect may not be modulated by endogenous neutral endopeptidase.


Opsonized zymosan decreases cytoplasmic motility of alveolar macrophages in dogs.

To examine the mechanisms of changes in alveolar macrophage (AM) activities caused by phagocytic stimulus, we studied the effect of opsonized zymosan (OZ) on cytoplasmic motility (CM) of AM from dog lungs in vitro. Four days after the instillation of ferrimagnetic particles (Fe3O4, 3 mg/kg) into the lower lobe bronchus, AM were harvested by broncho-alveolar lavage. AM were adhered to the bottom of plastic vials (10(6) cells of AM per each vial). Remanent field strength (RFS) from the AM containing Fe3O4 particles was measured immediately after magnetization. RFS decreased with time due to particle rotation (relaxation), which is related to cytoplasmic motility of AM. OZ (1-500 micrograms) decreased lambda 0 (the relaxation rate for the first min) in a concentration-dependent fashion. Neither BW755C (10(-5) M), indomethacin (10(-6) M), leupeptin (10(-5) M), bestatin (10(-5) M), nor superoxide dismutase (1000 U/ml) inhibited OZ (500 micrograms)-induced inhibitory effects on lambda 0, suggesting that cyclooxygenase and lipoxygenase products, serine, thiol enzymes, aminopeptidase and superoxide anion wer not responsible for OZ-induced effects. OZ (500 micrograms) significantly increased the intracellular concentration of Ca2+ (P less than 0.01). Likewise, OZ (500 micrograms)-induced effects on lambda 0 of AM were significantly inhibited by replacement of the medium with a Ca2+ free solution (P less than 0.01). These results imply that opsonized zymosan inhibits cytoplasmic motility of AM via external calcium influx.


[Systemic-psychodynamic model for family evaluation].

In this paper a family evaluation instrument called systemic-psychodynamic family evaluation model is described. Also, the second stage of the validation study of this instrument is presented (which deals with the inter-observers variation). Twenty families were studied. They were assessed always by the same interviewers designated as experts. They are all family therapy specialists and their assessment was used as the evaluation reference standard or "gold standard". The observers were psychiatrists without previous training in family therapy. For the purpose of the interview, both experts and observers were blind to the medical diagnosis of the patients. During the first stage of the validation study the observers did not have a reference guide which resulted in a low concordance rating. For the second stage, a 177 item guide was used and a considerable increase in the concordance rating was observed. Validation studies like the one used here are of considerable value to increase the reliability and further utilisation of evaluation instruments of this type.


Rapeseed diet and hepatocyte hypertrophy: an experimental morphometric study.

A previous study suggested that a rapeseed diet induced hepatocellular hypertrophy in normal albino rats. In the present study morphometry confirmed that a rapeseed diet produces hepatocytic hypertrophy which, according to cytological findings, is primarily due to an increase in the cytoplasmic area. A combination of a rapeseed diet and the administration of carbon tetrachloride (CCl4) also led to hepatocellular hypertrophy but the histological picture of the cirrhosis was similar to the one in control animals receiving CCl4 alone. The fact that the hypertrophy was primarily due to organelles supports the idea that a component or components of the rapeseed may modify protein turnover in the parenchyma of the liver.


[Role of liver biopsy in the diagnosis of prolonged cholestasis in infants].

Liver biopsy in the diagnosis of the results of a retrospective analysis of percutaneous liver biopsy in the differential diagnosis of prolonged cholestasis in infancy are reported. We compare the clinical features, serum bilirubin levels, hepatobiliary scintigraphy and histology in two groups of patients. One group of 56 patients had extrahepatic biliary obstruction (biliary atresia: 42; choledochal cyst: 9; extrinsic obstruction: 4; Caroli's disease: 1). Another group of 54 children had intrahepatic cholestasis with patent biliary tract (hepatitis: 38; non-specific cholestasis: 14; cirrhosis: 2). The percutaneous liver biopsy was better than the other procedures to differentiate biliary atresia from hepatitis. We conclude that percutaneous liver biopsy should be carried out in children with prolonged cholestasis when other non-invasive procedures have not ruled out extrahepatic biliary obstruction and before any surgical exploration of the biliary tract is performed.


[Prognostic importance of beta-2-microglobulin in multiple myeloma].

Beta 2 microglobulin is a low molecular weight protein found on the surface of all nucleated cells: it is the light chain of the HL-A histocompatibility complex. The increased levels of serum beta 2 microglobulin in patients with multiple myeloma have been associated with a poor prognosis. Pretreatment levels of serum beta 2 microglobulin were estimated in 70 previously untreated patients with multiple myeloma. In a multivariate analysis, serum beta 2 microglobulin levels and stage were the most significant prognostic factors for survival independent of other risk factors associated with a worse prognosis. There was a clear difference in survival duration observed between the patients with a high pretreatment level of beta 2 microglobulin and stage III (none alive at 5 years) compared with patients with normal levels and stage I (80% alive at five years) (p less than .001). We conclude that pretreatment-beta 2 microglobulin level is one of the most useful prognostic factors in patients with multiple myeloma.


[Adjuvant chemotherapy in gastric cancer. Experience at the National Institute of Nutrition].

The cases of gastric carcinoma treated with surgery plus chemotherapy (FAM) at the Instituto Nacional de la Nutricion (INNSZ) in Mexico City from January 1979 to December 1988 were reviewed. In 322 patients seen in this period, only in 12.4% (40 patients) it was possible to undertake curative resection; of these, twenty two received adjuvant FAM (fluorouracil, 600 mg/m2 IV days 1,2,3; doxorubicin, 30-35 mg/m2 day 1; and mitomycin-C, 10 mg/m2 in three days). Twenty patients were in stage III and two in stage II. At a median follow-up of five years, ten patients have relapsed; of these, eight died from progressive neoplasia; one is alive with no evidence of disease 24 months after receiving combined chemotherapy with 5-fluorouracil, cisplatinum and adriamycin, and one is alive with the disease. Nine patients (40.5%) are alive with no evidence of relapse 30 to 114 months after initial surgery. One patient died from unrelated causes with no evidence of relapse. Two individuals were lost to follow up at 9 months and 28 months, without evident malignant disease at the time of last consultation. The median survival was 61 months with a 51% estimated overall survival at five years. None of the prognostic factors analyzed were significantly associated with recurrence: number of metastatic lymph nodes; number of cycles of chemotherapy; interval between surgery and chemotherapy; and intraoperative blood transfusions requirements, although there was a tendency to relapse in the majority of the patients who received intraoperative blood transfusions as compared with the untransfused (five years disease free survival of 18% vs 64% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)


[Frequency and risk factors associated with metronidazole therapeutic noncompliance].

to determine the frequency and risk factors of non-compliance to oral metronidazole. comparative cross-sectional survey. 111 patients who received oral metronidazole. SETTING CHARACTERISTICS: two medical units: one primary level unit and one secondary care unit of the Mexican Institute of Social Security. non-compliance was assessed by home interview and pill count. frequency of non-compliance was 55%. Risk factors for non-compliance were: female sex (OR = 3.0; p less than 0.05); side effects (OR = 3.1; p less than 0.05); low literacy (OR = 3.75; p less than 0.05). Stratified analysis showed no interaction between variables. frequency of non-compliance to metronidazole is high, and could affect the effectiveness of medical care. Female patients with low literacy and who suffer side effects are a high risk group for non-compliance.


[Clinical, cytogenetic, endocrinological and histological studies in true hermaphrodites].

The clinical, cytogenetic, endocrinological and histologic features of nine mexican patients with true hermaphroditism are reported. Ages at admission ranged from 10 months to 27 years; in seven cases a male sex of rearing was documented, being 46,XX (n = 6) the most frequent karyotype. Basal levels of gonadotrophins, gonadal steroids, and the testosterone response to exogenous HCG varied depending upon age as well as with type and functional status of the gonadal tissue. However, ovarian tissue always preserved its function better than the testicular tissue did. In one of the patients who presented cyclic hematuria, spontaneous ovulation was documented by serum progesterone monitoring (progesterone = 4.3-11.0 ng/mL during luteal phase). Ovo-testis was the most common gonad present; in four cases bilateral ovo-testes were found. Internal genitalia varied depending on the existing gonad, although in all cases a uterus was found. These findings are in accordance with previous reports of individuals bearing true hermaphroditism in other populations.


[Effect of the treatment of hyperthyroidism on the course of exophthalmos].

The exophthalmos evolution in hyperthyroid patients was investigated: twenty patients were randomly assigned to treatment with radioiodine (group I followed 2-162 months) and 20 to treatment with thyroidectomy (group II followed 2-158 months). There was no correlation of sex age and follow up with exophthalmos evolution. In group I, exophthalmos improved in one patient (5%), did not change in ten (50%) and worsened in nine (45%). In group II it got better in six (30%), did not change in seven (35%) and got worse in seven (35%). The differences between the two groups were not statistically significant (p greater than 0.05). The postsurgical thyroid gamma-gram with one mCi of I-131 in group II showed absence of thyroid tissue in nine patients (45%) and remainders of the gland in 11 (55%) and apparently this did not influence the post treatment evolution. The length of pretreatment evolution did not influence the evolution post treatment. In summary, there was no correlation between exophthalmos evolution and kind of treatment in Graves' disease.


[Lung perforation by a small-bore enteral feeding tube].

A 68 year old male with multisystemic disease, mainly lungs and heart, was treated with a cuffed endotracheal tube, mechanical ventilation and a 16 Fr Levin nasogastric tube for feeding; it was substituted 13 days later by a 2.3 mm, 8 Fr O'Brien KMI polyurethane small bore enteral feeding tube introduced with a guide wire. The feeding tube perforated his right lung and passed into the pleural cavity, either through the larynx or through a nonconfirmed tracheoesophageal fistula; signs for the supposedly correct position of the tube were positive. In patients with depressed sensoria, abnormalities of gag or cough reflexes, esophageal strictures, significant cardiomegaly or tracheoesophageal fistula, small bore enteral feeding tubes should be passed under direct vision by laryngoscopy or preferably by flexible endoscopy; adequate confirmation of the correct position requires a chest and an upper abdominal roentgenogram.


Pulmonary mycobacterial infections associated with neoplasia.

Patients with cancer are at increased risk for disease caused by mycobacteria when there is immunosuppression resulting from the underlying disease or its treatment. Pulmonary disease is usual with Mycobacterium tuberculosis or with mycobacteria other than M tuberculosis (MOTT) and atypical presentations with extrapulmonary dissemination occur frequently. No clinical features reliably distinguish between disease caused by M tuberculosis or MOTT. The incidence of M tuberculosis infection depends on a history of prior exposure in patients and on patterns of disease within hospitals and the surrounding community. Infection with different species of MOTT reflects their environmental prevalence. Diagnosis of mycobacterial infection can be clinically challenging and must be pursued aggressively. Despite recent improvements in clinical and laboratory methods, diagnosis of mycobacterial infection may take weeks. Recent increases in the incidence of M tuberculosis infection and the emergence of drug-resistant strains require heightened alertness to its diagnosis and careful epidemiological control measures to prevent continued spread of this contagion. M tuberculosis with routine antimicrobial susceptibility responds well to conventional therapy when initiated early. Prophylaxis of tuberculin positive patients is effective and should be started before immunosuppressive therapy. Guidelines for therapy of MOTT depend on the species isolated but remains poorly defined in most cases. There are several new compounds that may be useful for treatment of drug-resistant species of MOTT. New methods for the rapid diagnosis, speciation, and epidemiological investigation of mycobacterial infection are being developed, and some are available for clinical application. Nonetheless, the timely diagnosis of mycobacterial disease in patients with cancer remains a challenge of increasing clinical importance.


[Dissolution of pancreatic calcifications with oral citrates in a woman with chronic idiopathic pancreatitis].

Pain control is one of the most important objectives in the medical treatment of patients with chronic calcifying pancreatitis (CCP). It is generally accepted that pain in CCP is secondary to the obstruction of the pancreatic duct by calcifications, protein plugs and stenotic areas. Experimental studies have shown that calculi and protein plugs are soluble in citrates. We report here the case of a young non alcoholic woman with idiopathic CCP who after a pancreatojejunostomy developed again pain and pancreatic calcifications which were dissolved with oral citrates. The case confirms previous observations and illustrates the potential use of citrates in subjects with CCP.


Pneumocystis carinii pneumonia among patients with neoplastic disease.

Pneumocystis carinii pneumonia (PCP) emerged in the 1980s as the most common opportunistic infection among patients with the acquired immunodeficiency syndrome (AIDS). Because of this, the presentation and clinical course of PCP has become well-known to many physicians. However, PCP continues to occur among patients not infected with the human immunodeficiency virus, generally those who receive immunosuppressive therapy as treatment for neoplastic disease. A review from Memorial Sloan-Kettering Cancer has shown that a new group of patients, those receiving corticosteroid therapy for brain neoplasm, are also at risk for the development of PCP and should receive PCP prophylaxis. Previously defined patient groups--people with acute lymphocytic leukemia or allogeneic bone marrow transplantation--also should continue to receive prophylaxis. In addition, the clinical course and outcome of patients with neoplastic disease who develop PCP may differ from those with AIDS and PCP: the disease may be much more fulminant among patients with neoplastic disease, and the mortality rate much higher, approaching 50% in the Memorial Sloan-Kettering Cancer Center series. Wider use of prophylaxis should decrease the frequency of this disease, whereas prompt initiation of therapy in patients with a compatible syndrome should help to improve mortality rates.


[New approaches to the measurement of clinical competence].

A new phase in the development of an instrument designed for the measurement of clinical competence is presented. The instrument (exam type) was previously validated; we report its use in three generations of students of a specialization course in internal medicine: those recently admitted to the course (group I); those finishing their first training year (group II) and those finishing the second year (group III). In the exam 304 out of the 600 questions included were classified as "experimental" (dealing with knowledge in internal medicine) and the remaining 296 questions corresponded to "control" questions (dealing with knowledge in other specialties). The variables considered in the exam were: 1) global result; 2) usage of diagnostic indicators; 3) omission of necessary procedures without a iatrogenic effect; 4) commission of unnecessary procedures without a iatrogenic effect; 5) omission of necessary procedures with resulting iatrogenic consequences; 6) commission of unnecessary procedures with resulting iatrogenic consequences; 7) global omission (variables 3 and 5); 8) global commission (variables 4 and 6); 9) global iatrogenesis (variables 5 and 6); 10) knowledge in nosology. Scores obtained by the three groups on the experimental questions differed in accordance with the respective time of clinical experience (group I obtained the lowest scores, group II showed intermediate scores, and group III showed the highest scores). Analysis of variance was significant (p less than 0.05) in variables 1, 2, 6, 8 and 9. The scores obtained by the three groups on the control questions were similar. In conclusion, we believe that this instrument is capable of detecting learning dependent on the time of clinical experience.(ABSTRACT TRUNCATED AT 250 WORDS)


[Overview of erythrocyte glucose-6-phosphate deficiency].

The cloning and sequencing of the G6PD gene has opened a new chapter in the characterization of the numerous G6PD variants described. Many which were thought to be different on the basis of their kinetic properties, are really the same whereas heterogeneity has been found in some which were thought to be homogeneous. We discuss with some detail variants A+, A- and the Mediterranean type.


Pulmonary infections after bone marrow transplant.

Pneumonia occurs in up to 50% of patients after bone marrow transplant and is the main cause of mortality. The patient may be predisposed to pulmonary complications by previous treatment and infections, by transplant conditioning and graft-versus-host disease prophylaxis regimens, and by prolonged severe immune-suppression. The period of greatest risk is within 3 months of transplant when focal or diffuse interstitial pneumonias may occur. The most common infectious etiologies are Aspergillus or other fungi and cytomegalovirus. Idiopathic, noninfectious, interstitial pneumonia occurring in this same period may represent treatment toxicity. Both fungal and cytomegalovirus infections have been associated with high mortality, but there has been significant success in treating cytomegalovirus with the combination of ganciclovir and immunoglobulin in recent years. Late bacterial pneumonia may occur more than 6 months after transplant because of prolonged immunedeficiency and functional asplenia. Prophylactic therapy to prevent the pneumonias anticipated after transplant should be an essential part of the care of the bone marrow transplant patient.


An approach to the diagnosis of pulmonary infections in immunosuppressed patients.

The goal of this review is to provide an approach to the diagnosis of pulmonary infections in immunosuppressed patients. First, a framework will be provided to narrow the extensive list of possible infectious and noninfectious pulmonary complications. This can be accomplished by considering the underlying immune defect, the pattern of radiographic presentation, the rapidity of progression of radiographic infiltrates, the typical temporal pattern of infection in specific disease states, and the local epidemiology at one's institution. Next, the yields and potential complications of invasive and noninvasive diagnostic techniques for pulmonary infections are reviewed. Lastly, algorithms, which account for the pattern of radiographic presentation, the primary disease and its underlying immune defect and the anticipated yields and complications of diagnostic procedures, are provided as a suggested plan for the use of diagnostic techniques and the institution of therapy.


Invasive pulmonary aspergillosis complicating neoplastic disease.

Invasive pulmonary aspergillosis is a necrotizing pneumonia that is most frequently seen in association with profound granulocytopenia as a consequence of cytotoxic chemotherapy that is used to treat hematologic neoplasms. There is considerable evidence that the incidence of this infection is increasing over the past decade as a result of improved medical support used in the management of "at risk" patients. Heightened clinical awareness coupled with advances in diagnostic techniques have led to earlier treatment and improved outcomes of this once uniformly fatal infection. Amphotericin B remains the treatment of choice; however, newer therapeutics (azoles) and strategies (combination chemotherapy, biological response modifiers) show promise as alternative regimens. Novel approaches in preventing the acquisition of pulmonary aspergillosis in the "at risk" patient are being explored.


An independent application accuracy evaluation of stereotactic frame systems.

The purpose of incorporating stereotactic methodology into neurosurgical procedures is to consistently achieve a high degree of accuracy and precision in localizing intracranial targets. Therefore, the limits of resolution for the therapeutic intervention itself are a function of the accuracy and precision inherent to the particular stereotactic frame system itself. The total clinically relevant error (application accuracy) comprises errors associated with each procedural step, including imaging, target selection, vector calculation and the mechanical errors of stereotactic frames. To evaluate these parameters, a systematic error analysis was carried out in the 4 most commonly used CT-compatible stereotactic devices: the Brown-Roberts-Wells, Cosman-Roberts-Wells, Kelly-Goerss Compass (modified Todd-Wells) and Leksell frames. Over 7,681 independent test measurements were made. The results suggest a potentially significant degree of error in application accuracy of all stereotactic instrumentation which is accentuated by imaging-associated error. These individual error values must be considered with every clinical use of stereotactic frames.


A universal system for interactive image-directed neurosurgery.

Stereotactic methods confer great accuracy to intracranial target localization, but require strict adherence to a complex program of mechanical and computational maneuvers. A computerized, articulated, localizing 'arm' has been developed that frees the neurosurgeon of these constraints and provides a completely intuitive, 'user-friendly' interface. This universal system is independent of whatever localizing fiducial system is selected. The arm may be sterilized for intracranial use. A variety of intraoperative end effectors may be selected. The patient's CT/MR/PET scans are loaded into computer memory and a three-dimensional shaded surface wireframe diagram of the patient's head is displayed simultaneously with up to 3 independent sets of cross-referenced CT/MR/PET scan images on the intraoperative video screen. The arm's endpoint location and the directional vector are shown as cursors on the relevant scan slices, and change continuously as the surgeon moves the arm. Because the information is continuously updated, an unlimited number of targets and trajectories may be displayed throughout the operation. The arm has an ultimate design accuracy for end-point localization to within 0.1 mm throughout a target volume of 40 x 40 x 40 cm. The tested application accuracy of the first prototype model is 0.31 mm. In clinical use during 30 surgeries, its real-world application accuracy is 0.9 mm. This system provides stereotactic accuracy and universally compatible, intuitive, interactive operation.


Further development and clinical application of the stereotactic operating microscope.

Implementation of a Vicom-VME image processing workstation for the frameless stereotactic operating microscope system has allowed an improved interpolation algorithm for more accurate reconstruction of three-dimensional data, the integration graphically of multimodality imaging information, an additional stereotactic graphics display outside of the microscope optics and optional three-dimensional displays through communication with a Convex mini-supercomputer. A precision-milled coupling for reproducible attachment of the spark gap bracket to the microscope has eliminated the need for that transformation calculation during each case. Clinical utility has been greatest in providing navigational guidance to small subcortical or deep lesions and in defining the extent of preoperatively planned resection of larger, infiltrating tumors. Mean accuracy in the past 17 cases has been 3.5-6.5 mm. The frameless methodology has also enabled extracranial stereotactic surgical procedures in 7 patients.


Stereotactic magnetic resonance angiography.

Visualization of the surgical trajectory with respect to the cerebral vasculature may enhance the safety of some stereotactic neurosurgical procedures. Traditional stereotactic angiography is tedious and, being an invasive procedure, poses some risk to the patient. A technique of projecting a stereotactically defined surgical trajectory onto magnetic resonance angiograms is presented.


In vivo and in vitro study of the lesions produced with a computerized radiofrequency system.

For many years, radiofrequency-generated lesions have been used for the treatment of pain and abnormal movements. However, the reliability of this method has been questioned because of the variation in the size of lesions produced by the electrode at different times and temperatures. A 500-kHz radiofrequency generator with different electrodes was used to determine the size of lesions, using different time and temperature exposures. A computerized feedback mechanism kept the tip temperature constant during the production of the lesion, regardless of varying tissue impedance. Eight electrodes of different size and tip characteristics were evaluated at different temperatures and time settings, both in vitro and in vivo. Graphic display of the curves in time were obtained at 65, 70, 75, 80, 85 and 90 degrees C. The effects of thermo-coagulation were studied in vitro in fresh egg whites, using time intervals of 20, 40, 60, 80 and 100 s, and in vivo, in the subcortical white matter of 20 adult New Zealand white rabbits. Animals were sacrificed after 7 days. Lesions were photographed and measured under magnification. In all cases, the coagulated masses were ellipsoid, with regular, well-demarcated borders. A two-way statistical analysis of variance was done. The coagulum size increased with higher temperatures and with larger probes. The increase was significant in both diameter and length (p = 0.001). In contrast, the use of different times at the same level of temperature showed no significant increase in most of the electrodes. There were two statistical significant time effects, for both diameter and length, with the monopolar 2-mm electrode. The use of real-time monitoring with graphic display and the feedback information provided for the computerized control of power and current allows high precision of the temperature at the electrode tip during the production of the lesion.


Positron emission tomography imaging-directed stereotactic neurosurgery.

The diagnostic yield of stereotactic biopsies depends upon safely sampling the most representative regions of masses. Potentially, localization information presently available from CT and MR scans might be improved by considering regional levels of cerebral metabolism by PET. In 10 selected stereotactic biopsies of intracranial mass lesions, PET scans were obtained using the Siemens CTI system; the Kelly-Goerss Compass system was used as the stereotactic development platform. PET-[18F]-fluorodeoxyglucose (FDG) images provided clinically significant information by appropriately directing biopsy efforts when CT and MRI was inconclusive or misleading. PET-FDG images can be successfully incorporated into routine image-directed stereotactic surgery.


Ventroposterolateral pallidotomy can abolish all parkinsonian symptoms.

Stereotactic ventroposterolateral pallidotomy in 46 parkinsonian patients resulted in a complete or almost complete and long-lasting relief of rigidity and hypokinesia in 91% of the patients. Good tremor effect was obtained in 80% of them. The L-dopa-induced dyskinesias, gait and speech improved in most patients. Complications were observed in 7 cases after 51 pallidotomies, i.e. 14% (partial homonymous hemianopia in 6 and transient dysphasia and facial weakness in 1). We believe that the good effect of surgery is based on interruption of some striopallidal or subthalamopallidal pathways.


Three-dimensional whole-brain mapping.

The implementation and use of a computerized whole-brain mapping system which can be used in conjunction with MRI, CT, angiographic and other brain imaging techniques is described. Three mapping systems based upon common reference structures about the third and fourth ventricular core of the brain are used in conjunction with internationally recognized nomenclature to create a normalized whole-brain mapping system according to the Talairach/Tournoux proportional grid technique.


Intraoperative brain mapping techniques in neuro-oncology.

Intraoperative brain mapping techniques are utilized in neuro-oncology to maximize the extent of tumor resection and seizure control, and minimize the operative morbidity. Direct stimulation mapping of the cortex and subcortical descending motor pathways will localize the rolandic cortex, dominant language speech zones and motor tracts in the internal capsule, cerebral peduncle and corticospinal tract/anterior horn cells. Electrocorticography identifies epileptogenic areas that histologically are distinctly devoid of neoplastic infiltration. Seizure control is maximal when seizure foci are resected in addition to the tumor nidus.


Corticoamygdalectomy in memory-impaired patients.

Sixty-seven patients who underwent resection of the amygdala and temporal neocortex for intractable temporal lobe epilepsy were analyzed. Forty-four of them failed memory tests during the intracarotid sodium amytal procedure or showed severe impairment of contralateral material specific memory. Surgical outcome ratings were seizure-free or rare seizure, 51%; worthwhile improvement, 15%; failure, 34%. The least successful outcome was noted in the group with mandatory corticoamygdalectomy and seizure origin in the dominant hemisphere. There was no postoperative exacerbation of memory deficit, whether preoperative memory was normal or impaired. When hippocampal resection is inadvisable, corticoamygdalectomy may be considered.


Surgery of central sensory motor and dorsolateral frontal lobe seizures.

Ten patients who presented with dorsolateral or frontocentral seizures were studied with chronic subdural grid electrodes. Cortical mapping, sensory-evoked potentials and chronic electrocorticography were obtained for each patient. Seizures were classified as focal, regional or dipolar. At the time of explanation, a selective functional corticectomy was performed. Surgical outcome is presented at a mean follow-up of 36 months. Two patients are seizure-free and 7 patients had a significant reduction in seizure frequency. One patient had no change in seizure pattern. Dorsolateral frontal lobe seizures have a focal functional anatomy and can be surgically treated by selective cortectomy.


Surgical outcome in computer-assisted stereotactic resection of intra-axial cerebral lesions for partial epilepsy.

A retrospective analysis was performed in 30 patients who underwent computer-assisted stereotactic resection of intra-axial mass lesions with intractable partial epilepsy. Mean follow-up was 4.1 years (2-5.5), mean age 21 years (3-45) and mean duration of seizures 8.4 years (1-26). Pathology consisted of vascular malformations in 11, glial neoplasms in 11, cortical dysplasia in 4 and gliosis in 3, and no diagnostic abnormality was found in 2 patients. The location of the lesions in some cases may have precluded a standard craniotomy and cortical resection, e.g. precentral gyrus (5), post-central gyrus (5) and deep-seated left posterior temporal region (4). Operative morbidity involved 3 patients who developed motor or language deficits. Four patients were lost to follow-up. Thirteen patients out of 26 (50%) were class I, 3 (12%) were class II, 4 (15%) were class III and 6 (23%) were class IV. These findings suggest that stereotactic lesion resection in selected cases (e.g. where lesions are located in eloquent brain regions) can be useful in providing a histological diagnosis of the epileptogenic foci and result in a favorable reduction in seizure activity without the need for a standard cortical resection.


Use of the callosal grid system for the preoperative identification of the central sulcus.

The callosal grid system based on modern imaging techniques facilitates the identification of the central sulcus by its relationship to the midcallosal plane. Imaging with or without the stereotactic frame allows precise localization of various anatomic sites, which can be compartmentalized within subdivisions of the grid system. The information gained permits accurate preoperative planning and intraoperative recognition of the central sulcus and adjacent neurovascular structures.


Comparison of CT- versus MRI-guided, computer-assisted depth electrode implantation.

Fourteen candidates for ablative seizure surgery underwent CT-guided, computer-assisted stereotactic depth electrode implantation and 21 underwent MRI-guided, computer-assisted implantation. A hand-held computer with no graphic capability was used for CT-guided procedures. A computer work station which included a high-resolution color graphics terminal with touchscreen interfacing and software capable of simulating targets and trajectories in single or multiple views was used for MRI-guided procedures. Previous phantom studies done with a 1.5-tesla MR scanner suggested acceptable localization error. Localizing information was obtained in 10 (71.4%) of 14 of the CT-guided implants and in 16 (76.2%) of 21 of MRI-guided cases. In the CT group, 7 (70%) were seizure-free and 8 (80%) were greater than 90% improved at 1 year follow-up. In the MRI group, 8 (80%) were seizure-free and 9 (90%) were greater than 90% improved at latest follow-up.


Surgical therapy of temporal lobe seizures.

Resection of epileptogenic lesions and pathological studies were performed in all 35 patients with temporal lobe epilepsy, 20 male and 15 female. Their ages ranged from 6 to 48 years with an average of 22 years. Various examinations including CT scan were carried out without any positive finding. EEG showed spike formation in the temporal lobes in all 35 patients. Epilepsy lesions were removed from the right temporal lobe in 22 patients and from the left temporal lobe in 13 patients. Pathological changes were found in all epilepsy lesions by light and electron microscopy. The operative outcomes were seizure-free since discharge in 10 patients (28.5%), seizure-free after some early attacks (34.2%) in 12 patients, seizure-free for 2 or more years and then rare or occasional attacks in 6 patients (17.1%), marked reduction of seizures in 5 patients (14.5%) and moderate or less reduction of seizure tendency in 2 patients (5.7%), with an effective rate of 93%. No death or severe complications did occur.


Cerebellar stimulation for seizure control: 17-year study.

Since 1974, 32 seizure patients have undergone chronic cerebellar stimulation (CCS); 27 have been contacted with 9 (7 spastic, 2 epileptic) continuing to use CCS for an average of 14.3 years (10-17 years). 6 (67%) are seizure-free and 3 (33%) have a reduction of seizure frequency. In the last 2 years, 2 other patients with spastic seizures, who were using CCS for 13 years, died of respiratory illness; 1 had been seizure-free and the other had a reduction. Of the remaining 16 patients (12 spastic, 4 epileptic) who did use CCS for an average of 8.3 years (2-14 years) and now have nonfunctioning stimulators, 5 (31%) continue to be seizure-free, 7 (44%) have a reduction and 4 (25%) have no change or a slight increase. Overall, 23 (85%) patients have benefitted from CCS. Stimulation charge densities were 0.9-2.5 microC/cm2/phase delivered at 10-180 pulses/sec to bilateral electrode pads on the superomedial cerebellar cortex. CCS is relatively safe and nonablative, and could be offered for patients with intractable seizures originating from bilateral or extratemporal foci.


Stereotactic thalamotomy for medically intractable essential tremor.

Objective surgical symptomatic outcome of ventrolateral (VL) thalamotomy specifically for essential tremor is uncommonly reported and functional outcome has not been investigated previously. In the present series, 7 patients underwent unilateral and 1 patient staged bilateral VL thalamotomies for disabling medically refractory essential tremor. At follow-up examination (mean 17.3 months, range 1-50 months), all patients enjoyed complete ablation or significant amelioration of the targeted tremor. Disability as determined by a modified form of an established rating scale for tremor was reduced from moderate (57%) or severe (43%) to absent (86%) or mild (14%). Interestingly, voice tremor was ablated or significantly improved in 71.4% of patients with preoperative voice tremor.


Ventral intermediate thalamotomy for posttraumatic hemiballismus.

An unusual case of hemiballismus following closed head injury is presented. The abnormal movement persisted for 16 years despite medical treatment. Preoperative studies did not reveal a specific lesion within the subthalamic nucleus or within the basal ganglia. A stereotactic ventral intermediate thalamotomy was performed producing a complete resolution of the ballistic movement which persisted for the length of our 12-month follow-up.


Neurosurgical treatment of spasticity: selective posterior rhizotomy and intrathecal baclofen.

The pathophysiology of spasticity and the history of posterior rhizotomies are reviewed. The rationale for selective posterior rhizotomies is that electrical stimulation identifies afferent posterior rootlets that terminate on relatively uninhibited alpha motoneurons; if these uninhibited rootlets are divided, spasticity can be alleviated without loss of other posterior root functions. Indications, technique, and results of selective posterior rhizotomies are presented. The use of continuous intrathecal baclofen (CITB) is summarized. CITB at doses of approximately 300 micrograms/day consistently reduces lower extremity spasticity and diminishes or alleviates muscle spasms in adults with spasticity of spinal origin. Single doses of intrathecal baclofen significantly decrease lower extremity muscle tone in children with cerebral palsy, and the effects can be maintained in these patients by CITB infusions which diminish muscle tone not only in the lower extremities, but in the upper extremities as well. CITB is best accomplished via an externally programmable pump that allows titration of the daily dose to attain the desired reduction in spasticity. Factors influencing the decision for rhizotomy or CITB are presented.


Magnetic resonance imaging and anatomic atlas mapping for thalamotomy.

A computerized anatomic atlas mapping technique has been developed and used to determine target sites for stereotactic thalamotomies. The digitized stereotactic atlases of Schaltenbrand and Bailey, Van Buren and Borke, and Schaltenbrand and Wahren are used in conjunction with an associated electrophysiological data base to determine the intended target site on MR images of the diencephalon. This mapping technique uses the 'Brierley and Beck' proportional hypothesis for thalamic nuclear determination. Target site determination by this method was found to be very accurate, and frequently the mere placement of the probe in the target site resulted in tremor cessation.


Application of magnetic resonance imaging in functional stereotactic thalamotomy for the evaluation of individual variations of the thalamus.

An application of MRI in functional stereotactic thalamotomy is presented. To estimate the individual anatomic variations of the thalamus prior to stereotactic thalamotomy, a special study using a proton density image that shows myeloarchitectonic features of the thalamus was performed. The proton density MRI was demonstrated to be very useful to determine the safest trajectory and tentative target point. However, as a detailed functional localization of the thalamic subnuclei cannot be yet obtained by MRI, the final target should be decided on the basis of electrophysiological findings.


Neurophysiological atlas created by mapping of clinical responses elicited on electrical stimulation of the human thalamus.

By computer processing of intraoperative neurophysiological data and intraoperative X-ray films, and using a 0.5-mm-step three-dimensional atlas created by interpolation of Schaltenbrand-Bailey's atlas, a neurophysiological atlas based on clinical responses upon electrical stimulation of the subcortical structures of patients who underwent stereotactic surgery in the awake state was created. There was considerable overlap in the distribution of motor and sensory responses in the vicinity of the ventral intermediate (VIM) thalamus: however, motor responses, particularly irregular movements, tended to be confined within the VIM and ventro-oralis posterior (VOP), whereas sensory responses tended to be localized in the VIM and ventroposterolateral nuclei, with considerable extension into the ventroposterior subthalamic region. In either motor or sensory responses, no definite somatotopic pattern could be determined.


A new multimodality correlative imaging technique for VOP/VIM (VL) thalamotomy procedures.

This paper describes our experience at Mayo Clinic with a new technique for planning ventro-oralis posterior (VOP) ventral intermediate (ventrolateral) VIM (VL) thalamotomy procedures for selected patients with medically intractable tremor. This new method employs a multimodality correlative imaging technique for determining the lesion target point on MR images. At surgery, stereotactic frame settings for the final lesion target were ultimately determined by stereotactic ventriculography modified by neurophysiological recording. Acceptable correlation was found between the multimodality correlative imaging method and the actual target coordinates determined by ventriculography and semi-microelectrode recording.


Spinal cord stimulation for multiple sclerosis: quantifiable benefits.

From 1984 to 1991, a quantitative study of 5 multiple sclerosis (MS) patients has been determining benefits from epidural (C7-T1 level) spinal cord stimulation (SCS). The 5 patients (4 male, 1 female; 4 tetraparetics, 1 hemiparetic) were 36-45 years of age having had symptoms for 12-22 years. Five quantitative tests were given prior to and during SCS on 4-8 occasions; 'off' periods were planned and also did occur when the electrode(s) broke (3 patients). With SCS, hand dynamometry showed a 2- to 4-fold increase in the 3 patients with weak hand function. Jebson Hand Time Testing showed a rapidity improvement to 1/2-1/7 of time in the same 3 patients. Minnesota Manipulation Testing with SCS was improved to 1/3-1/2 of time in 2 of these 3 patients tested. Manual muscle strength increased in all patients by 20-50% in 'normal range'. Ambulation in the parallel bars increased with SCS in 2 of the 4 wheelchair patients, while the hemiparetic patient could walk without his cane. All patients showed varying quantifiable improvements with SCS, but over the duration of testing the patients slowly deteriorated. SCS is a rehabilitation option for the weakened MS patient, to be used earlier rather than later in the deterioration of MS patients.


Pioneers of stereotactic neurosurgery.

The beginnings of stereotactic and functional neurosurgery can be traced as far back as 1873 when Dittmar reported the use of a guiding device for the placement of probes into the medulla oblongata in animals. Further pioneering work was done by Zernov and Altukhov in Russia (1889), Clarke and Horsley in England (1908), and Spiegel and Wycis in the United States (1947), as well as others. After a promising initiation, interest in stereotactic neurosurgery waned after the introduction of L-dopa in the 1960s. Later, the introduction and incorporation of new imaging technology into stereotactic techniques signaled the rebirth of stereotactic and functional neurosurgery as a versatile and exciting subspecialty not only in the resection of previously unresectable lesions but also in the functional restoration of central nervous system function. This brief paper will focus on the personalities that have pioneered stereotactic neurosurgery over the past century.


Central nervous system grafting: animal and clinical results.

In the 2 years since this topic was reviewed, there have been dramatic changes in our understanding of the basic science of central nervous system transplantation, as well as further realization of the crude state in which we find the clinical application of this technology. Early concepts of simple diffusion and neuronal replacement have been altered as we understand more the rule of neurotrophic factors and the response of the host to the transplantation process. Clinical studies are becoming increasingly sophisticated as we realize that the initial observations were frequently flawed and quantitative evaluations are increasingly important in determining the effectiveness of the procedure. There is, nevertheless, still a great deal of excitement in the field as new technologies are being developed and utilized in the clinical sphere.


Stereotactic technique and pathophysiological mechanisms of neurotransplantation in Huntington's chorea.

In Huntington's chorea, embryonal brain tissue (striatum) was implanted in the caudate nucleus bilaterally, using stereotaxy assisted by CT. A special cannula allowed the placement into the brain of 3 or 4 grafts of embryonal tissue along the determined trajectory by one introduction of the cannula. The pathophysiological mechanism of neurotransplantation in Huntington's chorea is to compensate for the degenerated striatal tissue by embryonal striatum, so it is necessary to supply a quantity of embryonal striatal tissue which enables the whole functional integrity. Therefore, we use material from several embryos.


Bilateral fetal grafts for Parkinson's disease: 22 months' results.

Five patients with severe Parkinson's disease underwent bilateral multiple graft implants of nondissociated fetal mesodiencephalic tissues. Graft implantation was performed in China following CT-guided stereotactic placement of a novel delivery system. Follow-up has demonstrated substantially reduced levodopa requirements and clinical improvements of motor, postural functions and reduction of freezing and on-off phenomenon. PET utilizing [18F]-dopa, at 14 months in the first case, suggested graft-induced restoration of dopaminergic transmission in the striatum.


Computer and imaging technology's impact on stereotactic neurosurgery. A 1987-1991 update.

Many improvements in computer and imaging technology have occurred since the last meeting of the American Society for Stereotactic and Functional Neurosurgery in 1987. These improvements are leading to a much wider acceptance of computerization and computer-assisted surgical procedures in the stereotactic neurosurgery field. This paper surveys the current fields of computer and imaging technology and its relationship and impact on the field of stereotactic neurosurgery during the period of 1987-1991. Forecasts about future developments are also discussed.


Stereotactic localization and guidance using a machine vision technique.

Machine vision techniques (video cameras) can be used to determine the three-dimensional position of objects. This transformation can be accomplished with standard mathematical algorithms. Initial accuracy tests of stereotactic localization with video cameras were performed using a standard Brown-Roberts-Wells (BRW) phantom simulator coupled with the BRW angiographic localizer. Localization accuracy was within 1.5 mm. Potential applications of machine vision techniques include freehand stereotactic localization of the position and orientation of surgical instruments. With sufficient computer speed these techniques can be used for continuous monitoring of the position of instruments within the cranial vault.


Utilization of image-derived computer-assisted stereotaxis in a community-based practice setting.

The success of a community-based stereotactic program is dependent upon community commitment, technological capability, referral base, patient/family support and, most importantly, proper patient selection. To develop a program of superior quality requires not only a substantial financial commitment, but also a basic philosophical approach which fully supports acquisition and education of support staff, physical plant renovation and an establishment of an expanding referral base. This report details the development of a highly sophisticated stereotactic program in Cedar Rapids, Iowa, a semirural community with a base referral population of approximately 300,000.


Using mark-recapture methodology to estimate the size of a population at risk for sexually transmitted diseases.

To study the spread of sexually transmitted diseases (STDs) using social/sexual mixing models, one must have quantitative information about sexual mixing. An unavoidable complication in gathering such information by survey is that members of the surveyed population will almost certainly have sexual contacts outside that population. The number of these outsiders may be substantial and, hence, important for the modelling process. In this paper, we develop a mark-recapture model for estimating the size of the population at risk for contracting a STD due to direct sexual contact with a specified population targeted by a survey. This mark-recapture methodology provides a reliable method of estimating the number of outsiders. Because not everyone in the targeted population may be sexually active, the size of the sexually active subset, used as the number marked in our tag-recapture formulation, must be estimated, which introduces extra variability. We derive an estimator of the variance of the estimated total number at risk that accounts for this extra variability and an expression for the bias of that estimator. We extend the methodology to stratified surveys and illustrate its use with data collected from a population of university undergraduates to estimate sexual mixing parameters of a deterministic model of the spread of STDs.


Effects of mid-point imputation on the analysis of doubly censored data.

Doubly censored data arise in some cohort studies of the AIDS incubation period because the time of infection may be known only up to an interval defined by two successive screening tests for HIV antibody. A simple analytic approach is to impute the infection time by the mid-point of the interval and then apply standard survival techniques for right censored data. The objective of this paper is to investigate the statistical properties of such a mid-point imputation approach. We investigated the asymptotic bias of the Kaplan-Meier estimate, coverage probabilities of associated confidence intervals, bias in hazard ratio, and the size of the logrank test. We show that the statistical properties of mid-point imputation depend strongly on the underlying distributions of infection times and the incubation periods, and the width of the interval between screening tests. In the absence of treatment, the median incubation period of HIV infection is approximately 10 years, and we conclude that, for this situation, mid-point imputation is a reasonable procedure for interval widths of 2 years or less.


Calculating the prevalence of cancer.

Incidence, prevalence and mortality are commonly used measures to assess the impact of disease on human populations. Prevalence, although regularly assessed for a number of different diseases, has only had recent use to measure the impact of cancer. The calculation of the prevalence of cancer presents several difficulties since there is no reporting mechanism established to measure the proportion of the community that has the disease. In the absence of such a mechanism, mortality data linked to incidence data from cancer registries have been used. The assumption is made that once diagnosed with cancer an individual remains a prevalent case until death. In this paper we present alternatives to this assumption and use them to produce estimates of cancer prevalence. We illustrate the effect of these assumptions on the calculated prevalence of cancer using data from the British Columbia Cancer Registry.


Estimation of a common risk ratio in stratified case-cohort studies.

The case-cohort study design is a useful modification of the case-control design, which allows direct estimation of the risk ratio without the rare-disease assumption. While several risk ratio estimation procedures have been proposed under large-strata settings, only the Mantel-Haenszel point estimator is available in sparse stratifications. This paper provides simple confidence limits methods, based on the large-sample distribution of the Mantel-Haenszel risk ratio, that apply to both large-strata and sparse-data situations. For the Tarone risk ratio, I give a new large-strata variance estimate.


Correlated binomial variates: properties of estimator of intraclass correlation and its effect on sample size calculation.

In group randomized studies, the sample size calculations are complicated by within group (worksite, community, etc.) correlation. We compare by simulation the moment method and the more standard ANOVA method of estimating the intraclass correlation. We find the former is less biased for a small to moderate number of clusters but the difference disappears when the appropriate degree of freedom is used for the ANOVA estimator. We propose a simulation approach for sample size determination and illustrate it with an example.


A note on last case influence using the partial likelihood approach under heavy censoring.

The Cox proportional hazards model always treats the last observation in a time ordered data set as an inexact survival time. In certain situations this can lead to this observation always having a low case influence and consequently never being highlighted by a case influence analysis. Thus an influential value can become non-influential by a miscalculation of survival time and this, in turn, can affect conclusions of an analysis based on statistical significance (P-values).


Caregiving demands: their difficulty and effects on the well-being of elderly caregivers.

Nurses assess situations involving elderly caregivers, yet data conflict on how caregivers perceive caregiving demands. To develop appropriate research-based interventions, more data are needed on specific aspects of these demands. Discussed are data from interviews with 60 elderly caregivers regarding tasks and personal demands. Results suggest that personal demands are perceived as more difficult than task demands and are associated to a greater extent with caregiver life satisfaction and depression. Issues are raised, however, regarding the measurement of expressed difficulty. Findings also support the adaptive capacity of these caregivers and their commitment to the caregiving role. Implications for nursing practice and nursing science are discussed.


Maternal role satisfaction: a new approach to assessing parenting.

There is a need to study the maternal role beyond the child's first year of life. This investigation, using a framework of Locke's expectancy theory, describes the expectations, surprises, values, and satisfactions experienced by 102 mothers of teens. Content analysis of written narratives describing surprises encountered by these mothers is also presented. Data were collected by questionnaire. Findings offer support for Locke's theory in two ways: (1) expectation for role was less important than value attainment in predicting the level of maternal role satisfaction, and (2) encountering at least one positive surprise was associated with a higher level of maternal role satisfaction. These variables are offered as a useful nursing approach to the assessment of the parenting experience. Knowledge of the satisfactions reported may be encouraging to mothers anticipating this stage of life.


Caring, virtue theory, and a foundation for nursing ethics.

The purpose of this paper is to critically examine the use of a framework of virtue theory as a foundation for a nursing ethic embodied in the caring ideal. The first section summarizes the problems identified with traditional moral theory as a foundation for a nursing ethic based on the caring ideal. From these problems, adequacy conditions that a foundation must meet are identified. In section two, the basic ideas of virtue theory are sketched and an account of how virtue theory can be used as a foundation for a nursing ethic based on the caring ideal is discussed. Finally, virtue theory as a foundation for a nursing ethic à la caring is assessed against the adequacy conditions delineated in section one. The conclusion of this paper is that virtue theory does not offer a viable alternative to duty-based theories. While virtue theory provides promise in meeting the identified adequacy conditions, serious secondary issues arise that can not be immediately nor easily resolved.


Physiological nursing research in dyspnea: a paradigm shift and a metaparadigm exemplar.

Dyspnea, the primary activity-limiting symptom in chronic obstructive pulmonary disease, is associated with respiratory muscle mechanisms. This leads to a paradigm shift from pulmonary processes to respiratory muscle function. Within the context of an integrative metaparadigm, basic and clinical nursing science are developed: to better understand physiological processes associated with dyspnea as presented in three physiological models of dyspnea, to identify respiratory muscle mechanisms associated with current treatment strategies for dyspnea, to eventuate clinical assessments of exercise endurance, and to generate treatment strategies in the promotion of positive life processes. The basic knowledge developed within this program provides a foundation for the generation of strategies to assess patients, to promote normal functioning of life processes, and to enhance positive coping with responses to illness. Thus, this research program provides a model for the development of substantive physiological and clinical knowledge for nursing practice.


Evaluation of a Swedish version of the Arthritis Self-Efficacy Scale.

There is a great need today for clinically useful instruments in the rehabilitation of chronic pain patients. The Arthritis Self-efficacy Scale measures patients' perceived self-efficacy to cope with the consequences of chronic arthritis. The aim of the present study was to evaluate a Swedish version of the Arthritis Self-efficacy Scale with respect to factor structure and reliability. Twenty-five chronic pain patients and twenty-four rheumatology patients were given a Swedish version of the Arthritis Self-efficacy Scale twice within a three week interval. The three factor structure of the scale was confirmed; Cronbach's alpha for internal consistency ranged between 0.82-0.91 and test-retest correlations ranged between 0.81-0.91, showing that the instrument satisfactorily met psychometric standards.


Basis of the quality of nursing care. A short quantitative description.

The purpose of the study is to create a descriptive evaluation basis for the quality of nursing care. In this article a short quantitative description of the most frequent elements of good nursing care is reported, using the views of Finnish nurses and nurse teachers. These elements are: interaction, comprehensiveness, need-centerness, initiativeness, technical procedures and knowledge-base. Based on these, further research areas can be seen both in nursing practice and in education.


The condition of the oral mucosa in institutionalized elderly patients before and after using a mucin-containing saliva substitute.

The purpose of this investigation was to evaluate whether the condition of the oral mucous membrane and the mouth comfort of the elderly could improve using a mucin-containing saliva substitute. In total, 52 patients were examined before and after a 60-day treatment period, with mucin-containing saliva substitute given three times a day before meals. The patients were examined with regard to weight, oral mucosa condition, the duration of meals, eating and swallowing. Before the treatment period the prevalence of stomatitis was 90.4% and oral candidosis was 80.8% compared to 15.4% and 5.8% respectively after the treatment period. The pH increased significantly. Artificial mucin-containing saliva substitute seems to be an adequate treatment of stomatitis and oral candidosis in elderly patients.


Greek fathers' participation in labour and care of the infant.

Greek fathers' (n = 157) reactions to their presence at the delivery, their expectations about the baby and their childcare practices were explored at the 4th-6th week postpartum. Only 10% of the sample attended the delivery. Their non-attendance was attributed, by the greatest number of fathers, to official hospital policy while the rest claimed it was entirely their decision. Half of the non-attenders expressed the desire to have been present while a large percentage of mothers were said to have wanted them to be present. The small number of fathers who attended the birth felt strong and satisfied. In respect to early fatherhood, three main themes were explored: reaction to fatherhood, enjoyment of the child and involvement in childcare. All three dimensions were strongly correlated.


Translation of an instrument. The US-Nordic Family Dynamics Nursing Research Project.

Translation of a research instrument questionnaire from English to another language is analyzed in relation to principles involved, procedures followed, and problems confronted by nurse researchers from the US-Nordic Family Dynamics Nursing Research Project. Of paramount importance in translation are translation equivalency, congruent value orientation, and careful use of colloquialisms. It is important to recognize that copyright guidelines apply in the translation of an instrument. Approaches to solving instrument translation problems are discussed.


The sense of coherence concept and its relation to personality traits in Swedish samples.

The paper proposes that Antonovsky's salutogenic orientation and his sense of coherence (SOC) concept provide a sound theoretical basis for the study and strengthening of the caring component in clinical practice. In order to study the operational utility of the concept, the 29-item SOC questionnaire (in two formats) was administered to five Swedish samples (3 groups of nurses, patients in a hospital emergency department, and a general population sample). Psychometric data are provided which test the internal and test-retest reliability of the SOC scale. A Self-Motivation Inventory (SMI) and the Karolinska Scales of Personality (KSP) were used to test the relation between the SOC concept and personality traits. The results revealed that those with strong SOC also scored as having more general motivation and less Somatic and Psychic Anxiety as well as less Hostility. In addition the data, though in some part modest in sample size, consistently supported the view that the SOC scale is a robust instrument. Particular note is taken of its crosscultural character and of its potential utility in clinical work.


Theory and methods for research on ethical issues in dementia care.

Swedish research on ethical issues in dementia care is almost exclusively done by nursing scientists. Many of these studies are rightfully acclaimed as exemplary research. But the strong focusing on the nurse and her relation to the patient tends to bias the ethical issues--the attitudes of other persons involved or affected are also in need of investigation. Further, there is a predilection for content analysis at the expense of causal analysis. In this paper an eclectic approach to the study of ethical issues in dementia care is advocated. More interdisciplinary communication and co-operation is also needed--especially between nursing scientists and moral philosophers. To facilitate such communication and co-operation a model for analysis of ethical issues is presented and discussed. To illustrate my ideas I use three articles by researchers from the department of advanced nursing in Umeå: Ekman & Norberg (1988), Norberg & Asplund (1990) and Akerlund & Norberg (1989-90).


Relaxation training as an integral part of caring activities for cancer patients: effects on wellbeing.

The purposes of this study were twofold. The first was to investigate if relaxation training conducted by nurses as an integral part of their caring activities affected breast cancer patients' experiences of radiotherapy sessions as well as their general wellbeing. Second was to evaluate a pedagogical model for large scale application of relaxation training as an integral part of caring. The sample consisted of 64 consecutive outpatients with breast cancer at a Swedish oncology clinic, receiving their first radiotherapy treatment course following surgery. Every second patient was assigned to an experimental group (n = 32, mean age: 59.5 years) and every other second patient was assigned to a control group (n = 32, mean age: 60.0 years). The programme resulted in the following general effects: fewer perceived daily hassles and a more cheerful overall mood state. The following treatment situation specific effects were noted: programme participants appraised the treatment sessions as successively more benign-positive and less threatening. They also reported more perceived muscular tensions during treatment sessions. Most goals concerning the routinization of the pedagogical model were reached.


[The temporomandibular joint].

With its discordant articular surfaces and complete division in two cavities separated by a disk, the temporomandibular joint appears as a complex anatomical and functional entity. Combined movements involving anteroposterior gliding between the disk and temporal bone in the upper cavity, anteroposterior condyle translation, hinge and rotation movements between the disk and mandibular condyle contribute to the different movements of the jaw. With dental occlusion, the masticatory apparatus therefore includes five functionally coordinated articular compartments. Various impairments of the normal static and dynamic features of the temporomandibular joint may lead to relatively frequent pathological conditions which can be easily diagnosed by modern imaging and arthroscopic methods.


Exercise training in obese diabetic patients. Special considerations.

The relationship between obesity and type II diabetes mellitus is well established and a majority of type II diabetic individuals are classified as obese. The pathogenesis of type II diabetes mellitus is not fully understood; however, multiple organ systems are involved, including abnormalities of insulin secretion, peripheral insulin resistance and hepatic insulin resistance. The goal of the treatment for the obese diabetic is to normalise these alterations and achieve normoglycaemia. Traditionally, the initial therapy, aiming to accomplish weight reduction, is diet and exercise. In obese type II diabetic patients, the whole body insulin-dose response curve is markedly depressed. A single exercise session improves and partially normalises both insulin responsiveness and sensitivity for glucose utilisation. Furthermore, a single bout of physical activity often results in decreased plasma glucose levels, which persists into the postoperative period. Type II diabetes patients participating in regular exercise programmes can potentially improve their metabolic control. An improved glucose control in both lean and obese type II diabetic patients under the age of 55 years has been demonstrated by improved HbA1C levels and glucose tolerance tests following physical training programmes. The effect of regular exercise on the metabolic control in these younger patients does not appear to be correlated with weight reduction. For most type II diabetic men over 55 years of age, physical training is not a feasible form of therapy because of other interfering diseases which may complicate or severely hinder all physical training apart from very low intensity exercise programmes. Lean, older, type II diabetic patients who have been able to exercise for 10 weeks or up to 2 years demonstrate no change in HbA1C levels, glucose tolerance or bodyweight. Thus, there is a clear difference in metabolic response to regular exercise between younger and older type II diabetic patients. The younger patient appears to be more inclined to respond to physical training with improvements in the metabolic control. The reason for this apparent difference is not clear, but possible explanations may include differences in training intensity, the presence or degree of complicating diseases, pretraining level of metabolic control or bodyweight. Type II diabetics are predisposed to cardiovascular disease and are characterised by hyperlipidaemia. In obese type II diabetic individuals, physical training improves the blood lipid profile as measured by decreased levels of triglycerides and total cholesterol. In young, overweight diabetics, improved lipid profiles can be achieved despite no change in bodyweight, while no apparent effects are reported for lean patients.(ABSTRACT TRUNCATED AT 400 WORDS)


Reproduction for the athletic woman. New understandings of physiology and management.

A physically active and athletic lifestyle is not only a healthy but a fulfilling choice for women. Although there is extensive literature on 'athletic amenorrhoea' which implies that exercise causes loss of the menstrual cycle, there is inadequate scientific evidence for a causal relationship. The reproductive system adapts to environmental, nutritional, emotional and physical stressors or 'threats' by downward adjustment towards the premenarcheal pattern. The hormonal milieu of this adaptation is low gonadal steroid and high glucocorticoid levels which synergistically increase the risk for a negative bone balance. Athletic women may become amenorrhoeic if reproductive immaturity, emotional stress and undernutrition coexist with increasing exercise loads. Treatment for athletic women with menstrual cycle changes requires that hypothalamic stressors be identified and decreased. In addition, as progesterone deficiency (from disorders of ovulation, whether flow is regular or absent) is the most prevalent menstrual cycle change, treatment with medroxyprogesterone on days 16 to 25 of their cycle will not only provide regular flow (if estrogen levels are sufficient) but will also promote increased bone density.


Head and neck injuries in soccer. Impact of minor trauma.

Head injuries have been shown to account for between 4 and 22% of soccer injuries. Clinical and neuropsychological investigations of patients with minor head trauma have revealed organic brain damage. 69 active football (soccer) players and 37 former players of the Norwegian national team were included in a neurological and electroencephalographic (EEG) study to investigate the incidence of head injuries mainly caused by heading the ball. 3% of the active and 30% of the former players complained of permanent problems such as headache, dizziness, irritability, impaired memory and neck pain. 35% of the active and 32% of former players had from slightly abnormal to abnormal EEG compared with 13 and 11% of matched controls, respectively. There were fewer definitely abnormal EEG changes among typical 'headers' (10%) than among 'nonheaders' (27%). The former players were also subjected to cerebral computed tomography (CT), a neuropsychological examination and a radiological examination of the cervical spine. One-third of the players were found to have central cerebral atrophy and 81% to have from mild to severe (mostly mild to moderate) neuropsychological impairment. The radiological examination of the cervical spine revealed a significantly higher incidence and degree of degenerative changes than in a matched control group.