Family dynamics, adolescent delinquency, and adult criminality.

Family and offending is probably the theme most researched in criminology. A comprehensive array of characteristics of family life have been linked to offending since the beginning of this century. This theme has been approached from two directions: a bivariable point of view, in which one characteristic of the family is related to a measure of offending, and a multivariate point of view, in which some family characteristics are used to explain offending. The literature is dominated by bivariable studies and although there are a few multivariate studies no specific theoretical perspective is proposed. In this paper we choose a control theory perspective and a comprehensive set of family variables to answer the following question: Can the explanation of offending be improved by a dynamic system family control theory? Additionally, the literature is principally focused on adolescent delinquency; in consequence we will study the following question: Are the family characteristics that explain most efficiently juvenile delinquency the same ones for the explanation of adult criminality?


Identification of children at risk at the police station and the prevention of delinquency.

In 1978 the World Health Organization suggested that the efficient use of health resources in a global context means paying special attention to those in greatest need. The aim of community health services should be, among other activities, to identify those "at risk" as early as possible in their lives and to intervene directly to reduce that risk (Skuse 1987). In the area of behavioral development, problems are frequently reported: In the Netherlands about 26% of all children appear to have some difficulties with behavioral development (Verhulst 1985). Set in the context of the WHO recommendation, these figures stress the point that early intervention with regard to children at risk should receive high priority from community educational health services.


Multiple-risk cohorts and segmenting risk as solutions to the problem of false positives in risk for the major psychoses.

This paper briefly reviews the past promise, current results, and problems that have resulted from application of the risk group approach to understanding the etiology of the major psychoses. The ultimate objective is to stimulate a change in methods that it is hoped will lead to the knowledge required to warrant intervention. Methods of intervention are not reviewed because it is considered more important at this time to improve our understanding of the life course of these disorders. Interventions can be justified when a body of well-agreed-upon findings has accumulated indicating the developmental pathways to the major psychoses, including the situational contexts. It is assumed that the timing and mode of intervention will be evident when these pathways have been delineated.


Defense behavior and coping in an autistic savant: the story of Temple Grandin, PhD.

The causal factors in the behaviorally defined syndrome of autism remain unclear, although the past decade has brought to bear two significant developments that shape our view of the disorder. The first of these developments is a growing body of biomedical research that indicates there are multiple etiologies associated with the disorder. This research has allowed for the formation of subgroups based upon neuroanatomical, neurobiological, and neurophysiological abnormalities (Damasio 1984; Piggot 1979; Ritvo et al. 1990). The second is neuropsychological research indicating that the socioemotional deficits are primary to the disorder and may underlie much of the behavioral symptomatology (Fein et al. 1986). These areas of concern undoubtedly have enhanced our understanding of the disorder, yet in their achievements they may too easily absorb what we know about autistics who experience a chronic state of physiological hyperarousal, evidence of which has been found in neurophysiological studies (Delius 1967; Hutt et al. 1965), neurochemical studies (Lake et al. 1977), psychopharmacologic studies (Ratey et al. 1987a), and behavioral studies (Kinsbourne 1980; Kootz et al. 1982; Tinbergen and Tinbergen 1972; Zentall and Zentall 1983). These individuals, perhaps constituting a subgroup of their own, experience an inner state of disorganization that markedly impairs their functioning (Sands and Ratey 1986).


Creatine kinase and enolase: intracellular enzymes serving as markers of central nervous system damage in neuropsychiatric disorders.

A frequently used method to assess cellular dysfunction and damage in humans is to document the presence of uniquely intracellular proteins in extracellular spaces. Thus, increased plasma levels of transaminases generally reflect hepatocellular damage (Lieber 1978), increases in the cardiac fractions of creatine kinase (CK, or CPK for creatine phosphokinase) or lactate dehydrogenase (LDH) are diagnostic for myocardial infarction (Armstrong et al. 1979; 1982), and increases of skeletal muscle fractions of CK may indicate myopathy (Goto 1974; Ford 1984). Similarly, a number of enzymes and proteins serve as tumor markers in a variety of malignant cancer (e.g., Concannon et al. 1974; Foti et al. 1977).


A mathematical model of the self.

I attempt here briefly to sketch a mathematical structure with properties analogous to key features of the self. This structure, while not easy to envision, is nonetheless as plausible a basis for theory as any science requires. I hope in this way to account for some aspects of the self that have long impeded systematic thinking on the subject.


Cohesion and desquamation of epidermal stratum corneum.

This article attempts to provide a comprehensive review on the roles of various classes of molecules in the cohesion and desquamation of the stratum corneum. In the first part of this monograph we review the field of epidermal differentiation in vivo and vitro, describing the expression and functions of a number of key structural molecules that characterize the process. In the second part we emphasize terminal differentiation and the biogenesis of the stratum corneum. The stratum corneum is a cell layer unique to fully differentiated squamous epithelia such as skin. While it is a dead stratum, it nevertheless is in a homeostatic process of continual shedding and renewal in synchrony with basal cell replication. It is also a degradative layer containing many proteinases and glycosidases in which a variety of intracellular and intercellular macromolecules are degraded. We highlight the molecules localized within the intercorneal matrix that are most likely to play a role in cohesion and desquamation, including: glycoproteins, lipids and enzymes. Because it is difficult to study the stratum corneum and desquamation in the native tissue, we discuss a number of model systems that have been used. The stratum corneum can be dispersed into single squames in different ways; these include mechanical dispersion as well as agents such as detergents and enzymes. The solubilized molecules and the structures remaining can then be studied as to their specific roles in desquamation. Using this approach it is possible to reconstitute multilayered structures that resemble a real stratum corneum. We have shown that glycoproteins play a key role in squame reaggregation and that this process can be modulated with amino sugars in a lectin-like fashion. Cohesion and desquamation can also be studied in tissue culture. Depending on the culture system, the extent of terminal differentiation and squame accumulation varies. Yet desquamation does not normally occur. It can be induced however by the inclusion of exogenous agents such as IFN-gamma which are found in the native epidermis but are absent in vitro. Modulation of desquamation by other exogenous agents is likely to yield further knowledge of how shedding occurs in vivo. Insight has also come from studies of scaling skin disorders. The glycoprotein and lipid profiles are altered in the stratum corneum in many diseases of aberrant terminal differentiation. A number of abnormalities in the levels of cytokines and growth factors have also been reported in the lesional tissue of such diseases.(ABSTRACT TRUNCATED AT 400 WORDS)


Fatty acid modulation of tumor cell adhesion to microvessel endothelium and experimental metastasis.

Tumor cell interaction with the endothelium of the vessel wall is a rate limiting step in metastasis. The fatty acid modulation of this interaction was investigated in low (LM) and high (HM) metastatic B16 amelanotic melanoma (B16a) cells. 12(S)-HETE increased the adhesion of LM cells to endothelium derived from pulmonary microvessels. All other monohydroxy and dihydroxy fatty acids were ineffective. LTB4 induced a modest stimulation but LTC4, LTD4, LTE4 as well as LXA4 and LXB4 were ineffective. The 12(S)-HETE enhanced adhesion of B16a cells was inhibited by pretreatment with 13(S)-HODE but not by 13(R)-, 9(S)-HODE or 13-OXO-ODE. 13(S)-HODE decreased adhesion of HM B16a cells to endothelium. 12(S)-HETE enhanced surface expression of integrin alpha IIb beta 3 and monoclonal antibodies against this integrin but not against alpha 5 beta 1, blocked enhanced but not basal adhesion to endothelium. Intravenous injection of 12(S)-HETE treated LM cells resulted in increased lung colonization (experimental metastasis). This effect was specific for 12(S)-HETE and was inhibited by 13(S)-HODE but not by other HODE's. 12(S)-HETE also enhanced lung colonization by HM cells and 13(S)-HODE decreased lung colonization by HM cells. Our results suggest a highly specific bidirectional modulation of metastatic phenotype and lung colonization by 12(S)-HETE and 13(S)-HODE.


Effect of the progesterone antagonist RU486 on human myometrial spontaneous contractility and PGI2 release.

We studied the effect of antiprogesterone RU 486 on spontaneous uterine contractility and PGI2 release with human myometrial strips superfused "in vitro". A decrease of PGI2 release into the superfusion medium was observed after 20 min superfusion. The inhibition was dose-dependent and reversible. After 20 min washing with tyrode medium without RU 486, the uterine strips recovered their initial rate of release. R5020, a progesterone agonist, did not affect PGI2 release nor dexamethasone and testosterone. Parallel to the decrease of PGI2 observed during RU 486 superfusion, the uterine spontaneous contraction frequency decreased, while the amplitude and duration of contractions increased. The alteration of uterine contractility was also rapid, dose-dependent and reversible. Modification of uterine strip spontaneous contractility, similar to those induced by RU 486, were also observed with superfusions of R5020 at concentrations as low as 10(-9)M, dexamethasone (10(-8)M), but not with superfusions of testosterone. These observations are not in favour of a progesterone-receptor mediated effect of RU 486 in our model. The mechanism of action may be related to the antiprogesterone specific structure i.e. the bulky substituent at the C-11 position. The RU 486 effect on uterine strip contractility, mimicked by other steroids, could point to a non-specific lipid/membrane interaction. However, the fact that testosterone did not affect motility, may indicate a possible specificity of steroids having a 3 oxo pregnene structure.


The effect of progesterone and human interferon alpha-2 on the release of PGF2 alpha and PGE from epithelial cells of human proliferative endometrium.

Progesterone and interferon-like trophoblastic proteins modulate prostaglandin (PG) synthesis from endometrium in early ovine and bovine pregnancy. Enriched epithelial cells were prepared from human endometrium removed in the proliferative phase of menstrual cycle (n = 8). Progesterone at a concentration of 1 microM suppressed PGE release from the cells during the first 24 hours in culture. After 48 hours in culture progesterone at a dose of 100 nM and 1 microM suppressed both the release of PGF2 alpha and PGE from the cells and this suppression was maintained for a further two days. Addition of exogenous 30 microM arachidonic acid (AA) abolished this effect of progesterone on both PGF2 alpha and PGE release. Interferon alpha-2 did not suppress the basal release of PGF2 alpha nor PGE. In the presence of progesterone, interferon alpha-2 attenuated the progesterone mediated suppression of PGF2 alpha but not PGE release from endometrial cells. These findings suggest that progesterone suppresses the basal release of PGs from human endometrium, but unlike the sheep, interferon alpha-2 does not exert this action on human endometrium.


[The psychodynamics of anti-Judaism in the historical perspective].

In the author's view, anti-Jewishness is the expression of covert anti-Christianism, which in its turn conceals an unconscious revolt against Christ. Unconscious aggression is unleashed against the Jews, who thus become scapegoats against whom three constantly recurring accusations are levelled: the killing of Christ; the desecration of the Host; and the ritual murder of children. The author traces the history of these accusations from the Middle Ages to the present. The search for scapegoats is a universal phenomenon not limited to anti-Jeweshness but encountered more generally in situations of social and political uncertainty. To substantiate his claims, the author draws upon historical documents from the Second World War dealing with the threat to China from Japan's armed forces, and also makes reference to the race riots in Los Angeles early this year.


Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 1. Comparison of patients' ratings, observers' ratings, and objective assessments.

The cosmetic and functional results of breast conserving therapy were evaluated in a sample of 76 patients with early stage breast cancer, treated by wide local excision, axillary dissection and postoperative radiotherapy between 1975 and 1985. A comparison was made between patients' ratings, independent ratings by two observers (an oncology nurse and a radiation oncologist) and objective measurements. In approximately 40% of the cases, moderate to large differences in the appearance of the treated versus the untreated breast were reported by patients and clinical observers alike. When evaluated on an individual level, the observers' ratings showed relatively high inter-rater agreement (kappa = 0.64), but low levels of concordance were found between the patients' and observers' ratings (kappa < 0.10). Approximately half of the patients reported limited arm or shoulder function, generally mild in nature. Compared to the patients', the observers' ratings of arm edema were significantly lower, indicating 20% mild and 5% more severe swelling. Objective measures of cosmesis and function correlated moderately with the observers' and patients' ratings. Both cosmetic and functional results were found to be significantly related to time elapsed since treatment, with patients treated longer ago exhibiting more problems. The cosmetic and functional outcomes were not related to the patients' age. The results suggest that the patients' opinion can provide important additional information in the evaluation of cosmetic and functional results of breast conserving treatment.


Cosmetic and functional outcomes of breast conserving treatment for early stage breast cancer. 2. Relationship with psychosocial functioning.

The relationship between cosmetic and functional results of breast conserving therapy and psychosocial functioning was examined in a sample of 76 patients with early stage breast cancer, who received treatment between 1975 and 1985. The patients were interviewed at their homes regarding breast cosmesis, arm functioning and psychosocial health, and subsequently attended the hospital for independent assessment of cosmetic and functional outcomes by clinical observers. High levels of psychological distress, disturbance of body image, and decreased sexual functioning were noted in approximately one-quarter of the study sample. About half of the patients expressed heightened concern with disease recurrence and their future health. Psychosocial problems were only modestly associated with treatment-related cosmetic and functional outcomes, as determined by clinical ratings and objective assessments. The patients' own ratings of breast cosmesis and arm functioning exhibited somewhat higher correlations with self-reported psychosocial functioning. In particular, a significant association was noted between the patients' ratings of overall cosmesis and arm edema and their body image (r = 0.48 and r = 0.43, respectively). The association between cosmetic and functional results and self-reported psychosocial health was strongest among those patients younger in age and treated longer ago. These findings suggest that, in order to evaluate the impact of breast conserving therapy on the patients' quality of life, the patients' own assessments of cosmetic and functional outcomes should be used as a primary source of information.


Multidisciplinary treatment approach to locally advanced non-inflammatory breast cancer using chemotherapy and radiotherapy with or without surgery.

Between April 1982 and December 1987, 82 locally advanced non-metastatic and non-inflammatory breast cancers were treated (42 stage IIIA, 40 stage IIIB). The median follow-up is 70 months from the beginning of the treatment. The initial treatment consisted of 4 courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by irradiation (45 Gy to the breast and nodal area). A fifth course of chemotherapy was given after radiation therapy. Three different locoregional approaches were proposed depending on the tumoral response. In 32 patients (39%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with multifocal tumors, mastectomy and axillary dissection were performed. Fifty other patients (61%) benefited from conservative treatment: 32 patients (39%) achieved complete remission and received a boost to the initial tumor bed; 18 patients (22%) who had a residual mass less than or equal to 3 cm in diameter were treated by tumorectomy and axillary dissection followed by a boost to the tumorectomy site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles). Three- and 5-year disease-free survival rates were 81.7% and 72% respectively. Five-year locoregional relapse rate (with or without other sites of failure) was 8.8%. In a multivariate analysis, disease-free survival was significantly influenced by the N-stage (p < 0.0001), initial tumor size (p = 0.01), and tumor response after initial chemotherapy (p = 0.02). Five-year breast conservation probability was 58.4%.(ABSTRACT TRUNCATED AT 250 WORDS)


Pathological features predictive of local recurrence after management by conservation of invasive breast cancer: importance of non-invasive carcinoma.

The pathological features of 236 clinical stage I and II invasive breast carcinomas treated by conservation were reviewed. On follow-up (minimum 2 years) 13 patients (6%) have developed breast relapse, 10 (4%) regional lymph node relapse and 26 (11%) distant metastases. Nineteen patients have died from breast carcinoma. On univariate analyses lymph node metastases, increasing amounts of non-invasive carcinoma and multiple foci of invasion were significant risk factors for breast relapse. A Cox's multivariate analysis showed the first two of these to be independently significant. The results are in agreement with other published series and confirm that assessment of non-invasive carcinoma is important. The study compares simple quantitation with the original method reported to define cases with an "extensive intraduct component".


Disappearance of the in situ component: a criterion predictive of metastasis in breast cancer after local relapse.

Local recurrence after conservative treatment of breast cancer is associated with a significant risk for metastasis. In order to identify criteria predictive of metastasis in this subset of women, we analyzed a series of 35 patients with local relapse among 512 consecutive patients treated with tumorectomy and radiotherapy. When relapse occurred within 2 years of initial treatment, overall 2-year survival from the time of local relapse was 39.5%. When local relapse occurred more than 2 years from initial therapy, 2-year survival was 80.5% (p < 0.001). Pathological slides of both initial and recurrent tumors were reviewed and compared. In 17 patients, local relapse and initial tumor had the same morphological features, with an in-situ component either absent or present in the same proportion. Metastasis occurred in two of these patients. In contrast, 9 of 12 patients in whom the proportion of non-invasive carcinoma had decreased at the time of local recurrence developed metastasis. Overall 2-year survival from the time of relapse was significantly better in the former group of patients (93.3% versus 52.5%, p < 0.05). We concluded that early relapses have a poor prognostic significance and that disappearance of the in-situ component or increase of the invasive component at the time of relapse is a feature predictive of tumor-related death and that more intensive therapy might benefit to this subset of women.


The management of carcinoma of the anal canal by external beam radiotherapy, experience in Vancouver 1971-1988.

From 1971 to 1988 72 cases of carcinoma of the anal canal were treated by external beam radiotherapy, most commonly by 5000 cGy in 20 fractions given over 4 weeks. The actuarial survival at 5 years was 66% and the disease specific survival 78%. Nine patients had inguinal node metastases at diagnosis; their 5-year disease specific survival was 75%. 63 patients were inguinal node negative at presentation; their 5-year disease specific survival was 78%, by UICC 1987 staging: T1 71%, T2 88%, T3 41%, T4 42%. 17 patients developed local recurrence; 10 were suitable for abdominoperineal (AP) resection which was successful in 7. The probability of local control was related to T stage. 13 patients were left with a colostomy because of recurrence, 2 had a colostomy for radiation damage and 4 had their local recurrence managed palliatively, without a colostomy. As a result, 53 of the 72 patients (74%) were left with a functional anus. Severe late complications occurred in 6 (8%).


Postoperative radiotherapy for rectal and rectosigmoid cancer: the impact of total dose on local control.

Between 1984 and 1988, 206 patients were treated with pelvic radiotherapy after macroscopically complete surgery for rectal or (recto)sigmoid cancer. Depending on an estimation of the amount of small bowel in the intended treatment volume a total dose was, in general, 45 or 50 Gy. An additional boost of 10 Gy was given to 6 patients because of microscopically involved surgical margins. For tumor stage B a statistically significant trend (p = 0.017) for higher local control with higher total dose was observed comparing patients treated with a total dose of 45 Gy or less, with more than 45 Gy but less than 50 Gy or with a total dose of 50 Gy or more. This finding illustrates the impact of total dose on local control for postoperative radiotherapy for rectal carcinoma.


Radiotherapy of germinomas involving the basal ganglia and thalamus.

Nine patients with histologically confirmed germinomas of the basal ganglia and thalamus (GBT) were treated by radiotherapy. The average dose of 52.5 Gy was delivered to the tumor bed, 37 Gy to the whole brain and 24.8 Gy to the CNS axis. The local control, which was verified by CT scan, was achieved in all patients. All patients are alive 11 to 96 months after radiotherapy. As with other intracranial germinomas, geminomas of the basal ganglia and thalamus respond well to radiotherapy and the prognosis is good after treatment.


Skin anergy and tuberculosis.

In our experience tuberculin skin anergy (negative response to 10 TU Mantoux) occurs in 8% of patients with tuberculosis. In this study we compare 81 patients with skin anergy and proven tuberculosis with a background reactive population of patients with tuberculosis. Patients with skin anergy and tuberculosis were older and had fewer symptoms--less cough, less sputum production, less haemoptysis, less malaise, less chest pain--than patients with skin reactivity. There was no difference with respect to male/female ratio, marital status, smoking habits, coexistent major illness, prescribed medications at diagnosis, nor the proportion of patients with extrapulmonary tuberculosis, previous history of BCG vaccination or past history of tuberculosis. Comparison of chest radiographs showed more advanced, more bilateral and more miliary disease in the anergic patients. Pyrexia and elevated ESR at diagnosis were also more common in this group. Fewer of the anergic group of patients were consistently culture negative after 1 month's treatment compared to the background population. Mortality was higher in the anergic group, but this excess mortality occurred from causes other than tuberculosis. Repeat Mantoux testing was performed in 20 of the 81 anergic patients, after a minimum of 3 months of antituberculous chemotherapy, and 14 had become tuberculin positive, suggesting that tuberculin skin anergy may be a temporary phenomenon.


Pulmonary eosinophilia with systemic features: therapy and prognosis.

Of 65 patients presenting with pulmonary eosinophilia to one Respiratory Unit during a 20-year period, 12 (18%) had systemic features associated with their pulmonary disease. Eleven had fever, three night sweats, three arthralgia, three vasculitic rashes and two weight loss. Anaemia, myalgia, peripheral neuropathy, mononeuritis, pericardial effusion and photosensitivity rash were each recorded in single patients. None had evidence of hypersensitivity to drugs, helminthes or other allergens. Ten of the 12 patients could be classified as cryptogenic pulmonary eosinophilia and two as Churg Strauss syndrome. Ten were female. The maximum recorded eosinophil counts were higher in the 12 patients with systemic features compared with the remaining 53 patients [mean (SD) 5613 (3883) vs. 2359 (3046) x 10(6) 1(-1), P < 0.02], whereas both asthma and recurrent episodes of eosinophilia were significantly less common. Steroid therapy achieved a good clinical response and radiological clearing in the majority of patients. All 12 patients were treated with prolonged duration oral prednisolone [mean (SEM) dose 8.5 (3.8) mg day-1 duration 5.5 (1.3) years]. The two patients with Churg Strauss syndrome required azathioprine in addition to long-term prednisolone. There were no deaths and currently four patients are off all steroids and six receive less than 5 mg day-1. During a median follow-up period of 11 years, there was no significant decline in FEV1 or VC, measured as percent predicted values. Persistent radiographic abnormalities consistent with fibrosis or bronchiectasis were not seen.(ABSTRACT TRUNCATED AT 250 WORDS)


AIDS, i.v. drug use and mycobacterial disease: the Dublin experience.

In the period 1980-1985, we treated 1641 patients for tuberculosis of whom two were known to be intravenous drug users (IVDU) and none had HIV infection. Of the next 1000 patients treated for tuberculosis (January 1986-December 1989), six were HIV-negative intravenous drug users (IVDU), 18 patients were HIV-positive (12 IVDU; six homosexual/bisexual). Statistical analysis (chi 2) showed a numerically small but statistically significant (P < 0.00001, d.f. = 1, chi 2 = 20.38) increase in intravenous drug users with a diagnosis of tuberculosis. The HIV-positive patients who completed treatment responded well to anti-tuberculous drugs. The importance of tuberculosis in the context of HIV infection is that it is preventable, treatable and is the only bacterial infection to which HIV subjects are prone which can be readily transmitted to a non-HIV infected subject.


High dose inhaled steroid therapy and the cortisol stress response to acute severe asthma.

Systemic absorption of inhaled corticosteroids taken in high doses (> or = 1500 micrograms beclomethasone dipropionate or budesonide daily), may cause suppression of the hypothalamo-pituitary-adrenal axis. Patients taking long-term high dose inhaled steroid therapy might therefore be at risk of adrenal crisis at times of stress. Plasma cortisol levels were measured in 24 adults with severe acute asthma who had not received treatment with systemic corticosteroids prior to hospital attendance. Seven were not taking inhaled steroids, four were taking 600-1200 micrograms and 13 were taking 1500-2400 micrograms beclomethasone dipropionate or budesonide daily. Plasma cortisol levels in these 13 (median 594 nmol l-1, interquartile range 399-620 nmol l-1) were similar to levels in those taking lower dose/no inhaled steroids (median 512 nmol l-1, interquartile range 287-1050 nmol l-1): there was no relationship between inhaled steroid dose and cortisol level. Nine of the 24 patients failed to achieve plasma cortisol values > 500 nmol l-1 (the normal response to an insulin stress test). When compared with the remaining 15, they had less severe asthma as indicated by higher arterial oxygen tension (P < 0.01) and peak expiratory flow (P < 0.03). Patients taking long-term high dose inhaled corticosteroids appear to be able to mount an appropriate adrenocortical response to the stress of severe acute asthma.


Audit of the use of erythromycin in the treatment of community-acquired lower respiratory infections.

The British Thoracic Society (BTS) guidelines for the treatment of community-acquired pneumonia recommend initial therapy with a betalactam antibiotic, with the addition of erythromycin if there are features of an atypical pneumonia. To see if these guidelines were being followed, a prospective study was undertaken of all adult patients admitted to hospital over a 3-month period who were given erythromycin for a community-acquired lower respiratory tract infection. Erythromycin was given to 62 patients who could be fully assessed. Continued prescription of erythromycin was justified in 10 (16%)--two patients with penicillin allergy, two with M. catarrhalis infection and one patient with legionnaires disease. Five patients had infections severe enough on admission to warrant combined therapy in line with the BTS recommendations. Five patients had erythromycin stopped on day 2. Erythromycin was prescribed on admission and continued unnecessarily in 47/62 patients, showing that the BTS recommendations are not being followed correctly.


The benefits of exercise combined with physiotherapy in the treatment of adults with cystic fibrosis.

The impact of exercise, physiotherapy, and combinations of exercise and physiotherapy upon sputum expectoration were compared in 18 adults with cystic fibrosis. Any treatment which included physiotherapy either alone or in combination with exercise produced a significantly higher sputum weight during treatment time than did exercise alone (P < 0.01). This trend was true for both high (greater than 35 g in 24 h) and low (less than 35 g in 24 h) sputum producers (P < 0.05). There were no significant changes in FEV1 and FVC 30 min after any treatment. The treatment option preferred by patients to continue at home was exercise followed by physiotherapy (P < 0.001). Exercise alone was less productive than the other three modalities in clearing sputum (P < 0.001).


[Unexpected hypoglycemia in hospitalized patients].

We analyze 40 episodes of unsuspected hypoglycemia (glycemia < or = 3.30 mmol/l) in 36 in patients during seven months in a tertiary hospital. Only 22% of them were diabetics, the rest had other risk-factors such as malnutrition (47%), infections (47%), liver diseases (22%), renal failure (19%) or neoplasias (17%). Only 14% of the subjects had symptoms related to hypoglycemia, and only 27% received treatment. There were no significative differences between those patients over 65 years and the younger ones. Hypoglycemia was not the apparent cause of death in any of the patients, but hospital mortality of these patients was 25%, and it was related with the number of risk factors. We conclude that hypoglycemia in hospitalized patients is often unnoticed, as it appears with diseases other than diabetes, and that it is related with a high mortality in patients with severe diseases.


[Short-term effects of respiration with external negative ventilation --shield-type respirator-- on the pulmonary function in COPD].

With the objective to test the effect of intermittent and short term rest in respiratory muscles in patients with COPD and maintained hypercapnia we have studied 34 patients in a stable condition: 23 were part of the study group (Group I) and 11 were the control group (Group II). After a complete functional basal study, patients in Group I were treated with intermittent rest of their respiratory muscles, through a negative pressure external respirator--shield type--during three consecutive days. We got, in this study group, a significative improvement in the maximum inspiratory pressure measured at residual volume (PI max RV), which went from 66.6 +/- 15.9 to 71.2 +/- 15.2 (p < 0.005), as well as a lowering, also significative, of partial pressure of CO2 in arterial blood (PaCO2) and in expired air (EFCO2), which went from 55.2 +/- 7.2 to 52.3 +/- 3 (p < 0.0002) and 3.3 +/- 0.5 to 3.1 +/- 0.5 (p < 0.01), respectively. Maximum inspiratory pressure measured to functional residual capacity (PI max FRC) experienced an increase in the limit of statistical signification. Rest of the parameters did not significantly change. These results back the hypothesis that in stabilized COPD with CO2 retention, a chronic fatigue of respiratory muscles could exist, and that intermittent rest of these muscles could mean an hypercapnia diminution, due to the improvement in the function of respiratory muscles.


[Pancreatic changes associated with acute gastroenteritis].

A retrospective study is discussed, in which the disorder of pancreatic enzymes in hospitalized patients because of an acute infectious gastroenteritis is analyzed. Of 30 cases, 15 showed a raise in lipase levels, being over 1,000 IU in five of them. There was no associated raise in amylase levels. Patients with high lipase levels did not show more fever, leucocytosis nor disorders on the hepatic enzymes, in comparison with those patients with normal lipase levels. Mean age was slightly lower in patients with high lipase levels than in those with normal lipase. Chronic diseases are not a predisposing factor to suffer pancreatic complications in patients with gastroenteritis. There was no case with intense abdominal pain which would suggest a pancreatitis, and a raise in lipase did not modify the evolution of the gastroenteritis.


[Complications of Gaucher's disease].

We discuss two cases of Gaucher's disease of the adult with neurological complications. First of the patients came to Hospital due to sudden pain in dorso-lumbar region and motor weakness of lower extremities. In the neurological exploration there were no concluding objective deficit signs except an unstable deambulation. After several hours of rest, symptoms disappeared progressively. In the radiology of the raquis a crushed in the last three dorsal vertebral was seen; this finding together with the clinic the patient showed, suggested a mild and transitory medullar compression. Second patient suffered an intraparenchymatous brain hemorrhage on the course of a platelet depletion and with other mild coagulation disorders. This type of complication have never been described in Gaucher's disease.


[Varicella pneumonia in adults. Study of 13 cases].

Clinical and therapeutic features of 13 adult patients, diagnosed of Pneumonia Varicellosa are retrospectively reviewed, for the last ten years period, at Valle de Hebron General Hospital, Barcelona. Most of them had a cigarette consumption of over 20 per day, three of them showed simple chronic bronchitis criteria, and two had antibodies against HIV. Respiratory symptomatology, and dry cough, was present in 9 (75%), dyspnea in 7 (53%) and pleuritic pain in 6 (46%). Thorax radiology showed a bilateral interstitial pattern. IV aciclovir treatment was begun in patients with respiratory symptoms and hypoxemia (53%) with good therapeutic response.


[Carbon monoxide poisoning. Report of 13 cases].

From November 1990 to February 1991 was had, in the Emergency Unit of Clinical University Hospital San Carlos, Madrid, 13 documented cases of intoxication due to Carbon Monoxide (CO), in patients with unspecific cephalalgia and asthenia and a possible CO source (total 19 affected people living together, because some of them did not came to hospital to consult). We consider that CO intoxication shall be always be beared in mind when doing the diagnosis at the Emergency Unit, especially during winter months, and that appropriate resources should be available to perform promptyl the analytical confirmation.


[Validity of the final diagnosis in the discharge reports of deceased patients in a teaching department of internal medicine].

In a transversal study with an observation period from January 1982 to December 1988, final diagnostics validity in discharge from hospital reports was analyzed, in those patients deceased in a Teaching Internal Medicine Department. We underline the use of terms such as "cardiorespiratory stop" or "possible, probable or could not be ruled out" as final diagnosis in 28.81% on the discharge from hospital reports in 812 deceased patients.


[Percutaneous mitral valvuloplasty. Immediate results with the 30 mm diameter dilatation balloon].

Percutaneous balloon dilatation of the mitral valve is a promising alternative to surgical treatment for patients with mitral stenosis. We analysed echocardiographic and haemodynamic results in 62 consecutive patients who underwent mitral dilatation with a big and one chamber balloon (30 mm diameter). The relationship between the dilatation balloon area and body surface was 4.2 (in 98% of patients it was bigger than 3.5). In the whole series we get significant improvements in the haemodynamic parameters and mitral areas (0.91 cm2 versus 1.78 cm2)(p < 0.005). According to the echocardiographic score, patients were divided in two groups. Good results (mitral area > 1.5 cm2, and final, valve area 50% greater than the initial area), were obtained in 93% of patients with a score of 8 or less, and in 45% of patients with a score bigger than 8. Seventy-five percent of patients with bad results (mitral area < 1.5 cm2) were in atrial fibrillation versus 37% of patients where we get a good results. Mortality of procedure was nulle, and two patients required surgery because of procedure failure for mitral insufficiency. We can conclude: percutaneous mitral valvuloplasty with single balloon is valid alternative, and good results can be expected if there is a good relationship between the area of balloon and patient's body-surface. The echocardiographic score and presence of atrial fibrillation can predict immediate results of this technique.


[Follow-up study after percutaneous mitral valvuloplasty. The COR-PAL experience].

Mitral balloon valvulotomy has proven to be an effective method for the treatment of patients with mitral stenosis. Although several factors determining an optimal immediate result have been described, there is few information regarding the longterm follow-up as well as factors influencing late success after the procedure. In this article, we analyzed our series of 311 patients treated by mitral balloon valvulotomy who were clinically followed between 3 months and 5 years (mean 23 +/- 11 months). At least, one echo-Doppler follow-up study was obtained in 260 patients, 20 +/- 10 months after. Hemodynamic re-evaluations were performed in 63 patients after 20 +/- 11 months. Late success was defined as the patient being in functional class I-II and free of major events (death, restenosis or valve surgery). Restenosis was defined as the loss of 50% of initial gain in terms of valve area, confirmed always hemodynamically. Major events during follow-up period occurred in 19 patients (10 deaths, 8 restenosis and 11 mitral valve surgery). We performed a multivariate study using the Cox-regression model. In the analysis, all variables with or near statistic significance in the univariate analysis (Mantel-Haezel) were included. The only significant independent predictors of late success were the presence of sinus rhythm (p < 0.04) and the absence of calcium at the valve (p < 0.001). In conclusion, the best results 5 years after mitral balloon valvulotomy are observed in patients with non calcified valve and sinus rhythm.


[Usefulness of transesophageal echocardiography in the critical patient].

To assess the usefulness and safety of transesophageal echocardiography in critically ill patients, we analysed the transesophageal echocardiography studies in 60 of such cases (age: 58 +/- 11 and 38 males). Every patient underwent a previous transthoracic echocardiogram, that was considered inadequate for diagnostic purposes. Thirty patients (50%), were on mechanical ventilation and 17 patients (28%) showed hypotension and/or shock. Forty patients (66%) were at special care units and in 31 (52%) of them, pulmonary and systemic pressures, and continuous analysis of venous pressure of oxygen were available. Indications for study were: 17 patients with clinical suspicion of aortic dissection (confirmed in 5 cases): 9 patients infective endocarditis (4 cases showed valvular vegetations); 6 patients with mitral prosthesis dysfunction (confirmed in 4 cases); complicated acute myocardial infarction (MI) in 8 patients (2 cases with mitral insufficiency, 3 with left ventricular dysfunction, 1 with right ventricular MI, 1 with left ventricular pseudoaneurysm and other with isolated inferior MI); in 11 patients the study was performed to evaluate the result of cardiac transplantation immediately (< 4 h) and it showed 2 cases of left ventricular dysfunction; 3 patients were studied for severe cardiac dysfunction of unknown etiology (a dilated cardiomyopathy was confirmed in one and ruled out in the other, and one patient showed signs of restrictive situation); there were other causes in the rest. The procedure could be completely performed in all cases. In conclusion in critically ill patients the transesophageal echocardiography has a great usefulness and minimal complications.


[Echocardiographic study of hypertrophic myocardiopathy in children. Distribution and changing morphological course].

Thirty-eight children with diagnosis of hypertrophic cardiomyopathy were analyzed by M-Mode, two-dimensional and Doppler. The patients ranged in age from 7 days and 20 years (average 5 years). Three groups appear, based in morphologic myocardial affection. Patients with biventricular involvement ranged in age from 20 days and 6 months (group 1), patients aged until 6 years with left ventricular concentric morphology by echocardiographic examination (group 2), and the older in age group (group 3) with localized mid-ventricular hypertrophy in the same ventricle. A certain degree of obstruction was detected in 15 cases (46.8%). In both this aspect and systolic anterior motion of mitral valve and mitral regurgitation, the highest frequency was obtained in group 3. With respect to others echocardiographic parameters, like isovolumetric relaxation time and left ventricle short fraction, no variations have been observed between the three groups. Very interesting is the fact that one third of the patients of group 1 improved markedly, and another third of cases died. In conclusion, the echocardiography permits identify three groups in the hypertrophic cardiomyopathy in children, according to age and anatomic region affected. The variability of evolution in the youngest group of patients, suggest that certain cases are not true myocardiopathies, but myocardial hypertrophies secondaries to other problems. Only the oldest group supply the classics parameters of the adult hypertrophic cardiomyopathy.


[Interventricular rupture following myocardial infarction. Surgical treatment and long-term follow-up].

The natural course of post myocardial infarction ventricular septal defect is towards cardiogenic shock and death. 50% in the first week, over 90% a year latter. Between 1973-1989, 28 patients where operated on. Before surgery 14 patients (53%) where in Killip IV, 5 patients (19%) in III, 5 patients (19%) in II and 2 patients in I. The repair was accomplished under hypothermia and cardioplegia, with the insertion of a Teflon patch to close the defect in 20 patients (70%). Complementary procedures (CABG, Pacemaker, repair of dissections) were performed in 12 patients (47%). Three patients (10%) could not be weaned from the pump; another 10 (36%) died before discharge: 2 with multisystem failure and sepsis, the other 8 with cardiogenic shock (4 with residual VSD). The only independent predictor of operative mortality, by univariate analysis, was preoperatory cardiogenic shock. All 15 survivors (100%) where followed between 5 months and 14.5 years (mean 104.5 months). Two patients died at 4 years, one at 10, another at 10.5 years. The actuarial probability of being alive after discharge was 100% at 4 years, 75% at 5, and 50% at 10 years. At last follow up only 2 patients had mild dyspnea, the remaining where asymptomatic. Surgical treatment provides an opportunity to improve this otherwise dismal survival and offers a surprising good long term result. An early diagnosis and efficient repair, before the onset of cardiogenic shock, should provide better results.


[Cervical aortic arch associated with cardiopathy].

We report five children affected with cervical aortic arch associated with tetralogy of Fallot (2), pulmonary atresia with interventricular septal defect (2) and pulmonary branch stenosis (1). Their ages were between one day and three months when they were diagnosed. With regard to one patient, the diagnosis was clinically suspected before catheterism. In four patients it was an angiographic finding since they didn't present the clinical signs when they underwent catheterism. One of these four patients showed such signs later. Only two cases can be inserted in Haughton classification; the other three can be included in the "unclassified group". Children's present clinical conditions are independent from this very rare anomaly and they depend on the associated heart malformations.


[Ebstein's anomaly with pulmonary hypoplasia. Diagnosis with Doppler color echocardiography in the fetus].

A case of Ebstein's anomaly with pulmonary hypoplasia diagnosed in utero by color Doppler echocardiography in a 26 weeks fetus is presented. We emphasize the importance of ultrasound in the early detection of this congenital abnormality that allowed our medical team to offer correct assistance to a severe ill child at birth.


[Swallowing syncope in a patient with diffuse esophageal spasm].

We present a patient with swallowing syncope. The esophageal manometric examination showed a diffuse spasm. This induces a vagovagal reflex mediated by tensoreceptors from the esophageal wall, which block the AV and/or sinus nodes.


[Supravalvular aortic stenosis and coronary aneurysm].

A 32-year old woman, with endocarditis caused by Streptococcus mitis, and systolic murmur is presented. The Doppler examination was found a systolic gradient of 150 mmHg. Aortography showed a multiple membranous supravalvular aortic stenosis, with aneurysmal dilatation of the left main coronary artery and circumflex artery, associated with bicuspid aortic valve and mild aortic insufficiency. The patient died suddenly by cardiac arrest in stand by to cardiac surgery. Anatomic comprobation was not possible. The coronary artery anomalies associated with the supravalvular aortic stenosis syndrome are reviewed.


[Let's stop using packet-years as expression of tobacco consumption].

It has become standard practice to describe the consumption of cigarettes by the number of "pack-years" obtained by multiplying number of packs per day by number of years. This leads conveniently to a single number summarising the overall tobacco consumption of an individual. Unfortunately, this summary is not relevant to the study of the effect of tobacco on health since it assumes identical effects of dose and duration, when the effect of duration is much larger than the effect of dose. If tobacco consumption must be summarised by a single number, the relevant figure is the duration of exposure to tobacco, ignoring the dose.


[Nitrosourea-induced lung diseases].

Nitrosoureas belong to the group of alkylating agents, and are increasingly used in the treatment of brain malignancies, due to their excellent penetration through the hemo-meningeal barrier. Since 1976, pulmonary toxicity from nitrosoureas has emerged as a significant problem, especially with BCNU, and 72 cases are available in the literature for review. While it is difficult to ascertain the exact prevalence of nitrosourea lung (estimate range between 1 and 20%), it is now clear that a direct relationship exists between cumulated exposure to the nitrosourea, and the likelihood of developing pulmonary toxicity. The clinical picture is that of a diffuse, severe fibrosis with hypoxemia. Histopathology, available in 55 reports, showed diffuse bland fibrosis. The outcome is poor with 67% of the patients dead by the time of publication. While we feel that corticosteroids should be tried for any possible beneficial effect, they seem to be of limited help.


[Evaluation of the extent of intra-thoracic lymph nodes. Role of mediastinoscopy].

Mediastinoscopy is a technique which enables palpation, inspection and biopsy of superior mediastinal glands. When this examination is done routinely in patients suffering from lung cancer which is presumed to be operable, 25-30% are found to have a positive gland and the greater part of these individuals become inoperable on account of significant invasion. The specificity of mediastinoscopy is 100% and this specificity ensures that no potentially operable patient would be refused a surgical cure. Anterior mediastinoscopy and an extended cervical mediastinoscopy are complementary techniques which enable the anterior mediastinum to be explored in patients suffering from cancer of the left upper lobe. In experienced hands, these techniques are safe and lead to little or no morbidity.


[Effects of coffee on the respiratory system].

The consumption of coffee is a very old and popular habit. It is possible that it may have an effect on the respiratory system and on the regulation of respiration. Apart from the manifestations of hypersensitivity linked to the handling of green coffee, the consumption of coffee can have different effects. On the one hand it has a beneficial effect on bronchospasm. On the other hand its consumption has been suspected of contributing to the development of chronic airflow obstruction (COPD) and also in the genesis of bronchial cancer, without, however, its responsibility being proven in a clear fashion. In fact, in these two latter pathological circumstances, the causal relationship is probably indirectly linked to the fact that there is a strong positive correlation between the consumption of coffee and of tobacco. Finally the consumption of coffee increases ventilatory frequency in normal subjects and also in the course of COPD, and if taken in large quantities by pregnant women, there is an increased risk of neonatal apnoea in the newborn, by an abrupt cessation in the caffeine level.


[Prognostic factors in survival of patients with obstructive respiratory insufficiency treated by long-term oxygen therapy. Data from the ANTADIR registry].

Prognostic survival factors in COPD patients obtaining long-term oxygen therapy (LTO) through 25 french associations were studied using data from the ANTADIR register. Selection criteria included age (50 to 79 yr), FEV1/VC < 60%, PaO2 < 60 mmHg and start of therapy between beginning 1984 and end 1988. A total of 1,775 patients were selected (1,462 men, 313 women, mean age 66.1 yr). PaO2 was 50.9 +/- 5.8 mmHg, PaCO2 47.1 +/- 5.8 mmHg, FEV1 8.81 +/- 0.31 l (30.4 +/- 11.1% of predicted values) and FEV1/VC 37.7 +/- 10.1%. Overall survival was 81.6% at 1 yr, 68.6% at 2 yrs, 55.7% at 3 yr, 44.9% at 4 yr and 37.3% at 5 yr (survival median 3.5 yr). Age was the most predictive survival factor (5 yr survival 48.8% for 50-59 yr-old patients vs 27.3% for 70-79). Survival was longer in women (49% at 5 yr vs 34.9% for men). After stratification by age, FEV1, FEV1/VC, PaO2, PaCO2 and Body Mass Index (BMI) were all significant predictive factors for men. FEV1/VC was the only prognostic factor for women. For all the population multivariate analysis showed that age, sex and BMI were the most significant variables. A prognostic score determined from the final Cox model and based on sex, age, BMI, FEV1, PaO2 will be validated in an independent patient series. Our data confirm the influence of age, airways obstruction and hypoxemia on survival of COPD patients under LTO. Furthermore they demonstrate a poorer survival in men, in underweight patients and in non hypercapnic patients.


[Amiloride hydrochloride nebulized by oxygen in the treatment of mucoviscidosis].

Bronchial inhalation of amiloride chlorhydrate has been suggested for a number of years in the treatment of the pulmonary disease in cystic fibrosis. However, physiotherapy remains invaluable in the struggle in containing pulmonary infections in this disorder. Physiotherapy may lead to a transient fall in the arterial oxygen as can sessions of nebuliser therapy which precedes physiotherapy. The originality of the system studied and proposed here for the administration of medication depends on an electronic control which guarantees that there is the nebulisation of a constant volume of medication with each inspiration. Triggered by inspiration the active principle nebulised is perfectly co-ordinated to the inspiratory cycle. A comparative chromatography carried out in this slides of silica-gel have enabled us to verify the absence of any degradation of the active principle contained in the nebuliser solution during the ten minutes period of aerosol therapy. Thus a quantification of the administered dose of Amiloride Chlorhydrate is made possible. In association with oxygen it enables an efficacious preparation of respiratory physiotherapy to children. As the expiratory tubing ends in a filter the fraction of the oxygen inhaled by the patient remains very high; 80% (V/V) of the medication is emitted in the form of liquid particles whose diameter lies between 0.5 and 5 micrometers. In practice in order to humidify the sputum and to restore the oximetry before the physiotherapy sessions, it seemed to us an interesting possibility to administer Amiloride Chlorhydrate and oxygen simultaneously. This is achieved in hospital by using wall-mounted oxygen (at a gas pressure of 3.5 bars).(ABSTRACT TRUNCATED AT 250 WORDS)


[An experimental anatomopathological study of pleural talcosis].

The aim of this work was to study the anatomical and pathological reaction and the mechanism of the formation of the pleural symphysis during pleural talcosis. The experiment was performed on fifteen dogs of similar breed, divided into three groups of five subjects each. After thoracoscopy under general anaesthesia, 2 ml of intrapleural physiological saline were injected in group I (controls) and 2 or 4 ml of talc granules in group II and III. A drainage tube was positioned at the end of the examination. One dog in each group was sacrificed on the 1st, 2nd, 7th, 15th, and 30th days post-thoracoscopy. At autopsy a detailed macroscopic study was carried out and some biopsies were taken for histology. In the control group, the inflammatory reaction was very moderate and rapidly disappeared whereas in the groups treated with talc, the talc led to an exudate of several millimeters, the exudate of inflammatory reaction was acute and early (J1) and involved the pleural in particular on the costal surface and was more moderate on the visceral surface and only involved the lung to a thickness of 2 or 3 mm and a few peripheral alveolar spaces. The granulomatous reaction occurred later (from the 3rd day) and was accompanied by the formation of a symphysis by the deposition and coagulation of fibrin which continued from the 7th to the 15th day, and became solid on the 30th day post-thoracoscopy. There was no significant difference between the two groups treated with talc, implying that the reaction was linked to the talc and was independent of the dose used.


[Tracheobronchial lesions after closed thoracic injuries].

We report the clinical picture and the outcome after medical and surgical treatment of eleven patients who had a traumatic rupture of the tracheobronchial tree between 1971 and 1990. The lesions occurred after a blunt chest trauma. All patients but one had evidence of extrapulmonary air leak on admission; one patient complained of hemoptysis. Seven patients underwent a fibroscopy on admission, which confirmed the rupture. One of them was operated immediately for tracheal rupture; four presented a small lesion which was medically treated; two were operated later on for secondary stenosis. Four patients didn't undergo a fibroscopy at first examination, one of them being asymptomatic. All four were operated secondarily. Of the six patients operated for secondary stenosis, three were operated within one month after the accident. This reflects the importance of other priorities at the initial stage. Of the three patients operated later on two didn't have a fibroscopy and it is impossible to assess the importance of the primary lesion. For the last patient operation was delayed because of the peripheral location of the lesion. The long term evolution was satisfactory in all cases.


[Pleural amyloidosis: thoracoscopic diagnosis and physiopathological approach].

The authors report a case of pleural amyloidosis presenting as a generalised primary amyloidosis with immunological disturbance, in which the diagnosis was made at thoracoscopy. Bronchopulmonary disease during the course of generalised amyloidosis is frequent, but there are only thirteen cases of histologically proven pleural amyloidosis which have been reported in the literature. Using pleuroscopy the histology obtained enables a pathophysiological approach to this disease, taking account of the cells and enzymes found in the pleura, the inflammatory reactions suggests a local production at the pleura level and this would explain the exudative character of some effusions, although a transudate is most often described and is directly linked to congestive cardiac failure. The deposit of fibrin by occluding the stomas of Wang, explains the failure of the absorptive properties of the pleura and also the recurrent nature of these effusions. The pleural disease is without doubt, under-estimated in generalised amyloidosis and the character of the effusions variable. Most often there are transudates secondary to congestive cardiac failure, although exudates occur as a result of local inflammatory phenomena. Amyloidosis should be remembered as a possible cause of exudative pleurisy.


[Acute pneumopathy caused by exposure to zinc oxide].

The authors report the case of an acute lung reaction due to an accidental exposition to zinc oxide. This episode showed features of metal fume fever. The bronchoalveolar lavage showed an increased cellularity (1,300 cells/mm3) with 28% neutrophils and 25% eosinophils. The characteristics of pulmonary disease associated with fever associated to exposure to zinc, as well as its pathogenic mechanism are discussed.


[Interstitial fibrosing pneumopathy and dermatomyositis. Pulmonary histology and prognosis].

The authors describe a case of interstitial lung disease associated with dermatomyositis. Alveolar-interstitial shadowing on the initial chest X-ray, lymphocytosis on the broncho-alveolar lavage fluid, absence of anti-JO1 antibodies and presence of intra-alveolar buds on the open lung biopsy were observed. Our patient died of acute respiratory failure, 34 months after symptoms onset. Intra-alveolar buds found at an early stage of dermatomyositis interstitial lung disease, were associated with minimal interstitial cellularity, markedly interstitial fibrosis, poor prognosis and poor response to steroid therapy. In contrary, bronchiolitis obliterans organizing pneumonia noted at an early stage of interstitial lung disease associated with both dermatomyositis and polymyositis, seems to have better prognosis and response to corticosteroid, especially if associated with polymyositis.


[Value of magnetic resonance imaging in the detection of intramedullary metastases of bronchial epidermoid carcinoma].

A 68 year old female presented with an intramedullary metastasis which was found to be caused by an epidermoid bronchial carcinoma. This type of metastasis is a rare complication and a diagnosis is difficult. The authors stress the importance of nuclear magnetic resonance as a non-aggressive diagnostic method which is very sensitive in detecting this type of pathology.


[The multifocal form of bronchocentric granulomatosis].

Bronchocentric granulomatosis is a rare entity and has only recently been characterised. We report a case of a forty-three year old man presenting with multifocal bronchocentric granulomatosis which was revealed following some oto-rhino-laryngological and bronchopulmonary symptoms. The open lung biopsy confirmed the diagnosis. Treatment was by bolus doses of corticosteroids (30 mg/kg) and of methotrexate in low dosage (7.5 mg/week, then 15 mg/week) which checked the initially unfavourable outcome.


[Mediastinal-pulmonary sarcoidosis with unilateral pseudotumorous presentation. Apropos of a case].

We report a case of a patient of forty two years who was admitted with a chronic cough and had a left hilar "tumour". Scanning showed a hilar opacity with an air bronchogram. Fibreoptic bronchoscopy did not succeed in achieving a precise diagnosis, the biopsies showed no sign of malignancy. An open lung biopsy was necessary to establish the diagnosis of pulmonary mediastinal sarcoidosis with a pseudo-tumoral presentation and localised unilateral disease involving a segmental bronchus and the left upper lobe. There was a rapidly favourable outcome after treatment with steroids.


Basic principles of laboratory medicine.

In order to successfully apply laboratory tests to the solution of clinical problems, a clinician needs to select tests that are appropriate to the suspected disease, collect and submit the necessary specimens, and recognize sources of variation that affect test results. The clinician must have confidence in the accuracy and precision of analytical methods used to produce results. An understanding of reference ranges and test performance in healthy and diseased animals is necessary for accurate interpretation and clinical decision making.


Specialized hematology tests.

In conclusion, many specialized tests for the evaluation of anemia and RBC abnormalities can readily be performed in-house or by commercial laboratories. Tests include RBC indices, examination of blood smears (for morphological changes, infectious agents, basophilic stippling, and polychromasia), reticulocyte counts, iron stains, serum iron determinations, Heinz body counts, and methemoglobin tests. These diagnostic tests should routinely be used for the evaluation of hematologic abnormalities that are detected by a CBC. Accurate interpretation of test results will provide vital information on the pathophysiological and/or etiologic mechanisms of disease and point the way to successful therapeutic intervention. Failure to adequately resolve some hematologic abnormalities, particularly in breeds in which heritable disease is a consideration, may require additional tests, including serum haptoglobin, ferritin and erythropoietin measurement, or assays for RBC enzymes, such as methemoglobin reductase, PK, and PFK. These tests usually are available only through research laboratories or hematology specialists, and it is advisable to consult with a veterinary clinical pathologist for referral to the appropriate individual or laboratory.


Levels of plasma lipid peroxides before and after choledocholithotomy in patients with obstructive jaundice.

Plasma lipid peroxide levels were measured in a group of 40 healthy controls and 11 patients with jaundice. In the case of these 11 patients, we checked the plasma lipid peroxide concentrations prior to and after choledocholithotomy. Before choledocholithotomy, there were significantly higher mean concentrations of plasma lipid peroxides and bilirubin in patients with jaundice than in the control cases (11.8 +/- 2.3 vs. 2.0 +/- 0.1 nmol/ml and 10.3 +/- 1.82 vs. 0.7 +/- 0.03 mg/dl, respectively, P < 0.05). In addition, patients with jaundice had lower plasma vitamin E levels in comparison to the controls (8.2 +/- 0.6 vs. 12.2 +/- 0.5 micrograms/ml, P < 0.05). In patients with jaundice, the increased plasma lipid peroxides were clearly related to the serum levels of bilirubin (r = 0.87, P < 0.05). After surgery, the higher plasma levels of lipid peroxide and bilirubin were reduced markedly (11.8 +/- 2.3 vs. 3.7 +/- 0.4 nmol/ml and 10.3 +/- 1.82 vs. 3.1 +/- 0.47 mg/dl, respectively, P < 0.05) with the restoration of bile flow which was associated with improvement in liver function tests. Consequently, these results suggest that there is an involvement of lipid peroxidation in liver cells damaged by obstructive jaundice in patients with cholelithiasis, and that these high plasma lipid peroxide levels may correlate with the severity of the disease.


[The significance of obesity in UOEH medical students--multiple regression analysis of the annual physical checkup data in 1991].

For the purpose of evaluating the significance of obesity in a young population as a risk factor toward various chronic diseases, a multiple regression analysis was performed on the data from the annual physical checkup of medical students of UOEH in 1991. The following results were obtained. (1) The average obesity index of the students showed a progressive and significant increase in the past 13 years from 1979 to 1991. (2) A close correlation between the obesity index and serum GPT was recognized by elevation of the standard partial regression coefficient of serum GPT to obesity index and that of obesity index to serum GPT when the data from all 617 students was analysed in one group. This finding was intensified in 142 obese students with an obesity index of over 10%, but it was not seen in the remaining non-obese students. (3) The correlation between the obesity index and serum GPT was found solely in the group of students with constant obesity; i.e., whose obesity index was always more than 10% during a maximum of 9 years in the past. (4) Systolic blood pressure was related to the red blood cell count rather than to the obesity index in this young population. (5) No particularly close correlation to serum cholesterol was found with any of 10 representative items examined in this physical checkup, including the obesity index, indicating that the other factors should be related to serum cholesterol levels. From the above findings, it can be concluded that constant obesity in students is related to liver dysfunction, probably due to fatty liver frequently seen in the precise examination of these individuals.


[Determination of common esterase D phenotypes by HPLC].

The analysis of blood Esterase D (ESD) phenotypes was performed by using high performance liquid chromatography (HPLC). The hemolysate was first treated with a cation exchanger to remove hemoglobin, injected into HPLC on a weak anion exchange column, and developed to become fluorescent with reaction reagent. The chromatogram of each ESD phenotype was distinct from those of the other phenotypes. ESD protein was confirmed by isoelectric focusing in the HPLC fraction that was referred for ESD typing. This HPLC method can be used to determine the common ESD phenotypes in blood.


[Sarcomatoid liver carcinoma diagnosed clinically as hemangioma].

This is a case report of a 69-year-old woman with sarcomatoid hepatocellular carcinoma (HCC), which was diagnosed clinically as hemangioma. She was first admitted to our university hospital, complaining of general fatigue in December, 1988, and cholelithiasis and liver cirrhosis with hepatic tumor in Segment 8 were diagnosed. The serum AFP level was within normal range, and the tumor was diagnosed as hemangioma radiologically. She underwent only cholecystectomy and was well without any therapy for the liver tumor up until March in 1991 when she was readmitted to our university hospital due to rapidly progressive liver dysfunction. The size of the liver tumor was unchanged. Despite intensive care, she died of hepatic failure due to cirrhosis in a decompensation state. At autopsy, a well defined yellowish white tumor of 3 cm in maximum diameter was seen in the cirrhotic liver. Although the largest part of the tumor revealed necrosis and hyalinization, a sarcomatoid part composed of spindle-shaped cells was noted in the peripheral portion. In addition, some necrotic ghost cells, probably hepatocellular carcinoma, were also noted. Low molecular cytokeratin, which is always found in HCCs, was seen in spindle-shaped sarcomatoid cells. The liver tumor was diagnosed as sarcomatoid HCC from these pathological findings. We report this histologically unusual HCC with an immunohistochemical study.


Swimming and asthma. Benefits and deleterious effects.

Swimming is a common pastime activity and competitive sport for patients with asthma. One reason for such popularity may be the low asthmogenicity of swimming compared with landbased activities. Review of available evidence suggests that swimming induces less severe bronchoconstriction than other sports. The mechanisms for this protective effect of swimming are not clear, but there is some experimental evidence intimating that it results in part from the high humidity of inspired air at water level, which reduces respiratory heat loss (and possibly osmolarity of airways mucus). Beneficial roles of horizontal posture and of water immersion have been tested but not confirmed. Swimming poses two potentially deleterious effects to the patient with asthma. One is the exaggerated parasympathetic tone due to the 'diving reflex', that has been shown to trigger bronchoconstriction. The other is airway irritation because of chlorine and its derivatives. Swimming as a training modality has definite benefits for the patient with asthma. These include an increase in aerobic fitness and a decrease in asthma morbidity. There is no conclusive evidence, however, that swim training causes a decrease in the severity or frequency of exercise-induced bronchoconstriction.


Aging and muscle function.

Most of the available data on the aging of muscle function are cross-sectional in type. Static and dynamic muscle strength seem well preserved to about 45 years of age, but performance deteriorates by about 5% per decade thereafter. There is a parallel loss of lean tissue. Because muscle biopsy specimens are not always representative of an entire muscle, it is unclear whether there is a general hypotrophy or atrophy of the muscle fibres or a selective hypoplasia and degeneration of type II fibres associated with a loss of terminal sprouting. Other influences may include a deterioration of end-plate structures with impaired excitation-contraction coupling and impaired fibre recruitment. Both contraction time and half-relaxation time are prolonged with aging, and there is a decrease of maximal contraction velocity, more marked in the legs than in the arms. On the other hand, endurance at a fixed fraction of maximal force is increased. Potential factors leading to the enhanced endurance include a poorer maximal effort and an increased proportion of type I fibres; however, there is little evidence that muscle capillarity is altered. The loss of function is generally less in the arms than in the legs, but it remains unclear whether this is an inherent biological difference, or merely a reflection of differential changes in activity patterns between the upper and the lower limbs. The male/female strength ratio does not seem to change with age, but substantial slowing or reversal of the aging process is possible through appropriate activity programmes. The preservation of muscle function has important implications for the quality of life in the frail elderly, counteracting dyspnoea, stabilising joints and extending the period of independent living by up to 20 years.


Acute and chronic adaptations of muscle proprioceptors in response to increased use.

Acute adaptations to use have been shown to occur in both the muscle spindle and Golgi tendon organ pathways. This short term activation adaptation increases the excitability of the motoneuron pool, thereby potentially providing a nonvoluntary increase in the excitation of subsequent contractions. It is thought that the intrafusal muscle fibres reset to a higher gain after contraction and that the tendon organ pathway undergoes a brief desensitisation. These phenomena could be important clinically when trying to stretch muscles, i.e. a contraction before a stretch should make the stretch more difficult. Also, this could affect the amount of muscle force generated, thereby altering motor behaviours requiring fine accuracy. Research on the adaptations of proprioceptors during free movement, using locomotion as a model, has found that the hypothesis of consistent alpha-gamma coactivation during motor behaviours is much more complicated and adaptable, depending on the environmental circumstance and the specific motor task. These research findings support the use of selective training, i.e. training to the task, for optimal motor learning. The results of the relatively limited research on chronic adaptations of proprioceptors due to exercise has shown that on a microlevel, the intrafusal muscle fibres may show some metabolic changes but do not show any hypertrophy. However, on a more macro level, with extended training, the latency of the stretch reflex response is found to be decreased and the amplitude is found to be increased in both animals and humans. Through classical conditioning research, proprioceptors may also be necessary for motor learning. Lastly, both primates and humans have been shown to be able to up- or down-grade their stretch reflex responses using operant conditioning techniques and many practice sessions. These findings have important implications both for rehabilitation of persons with abnormal reflex activity and in the training of athletes. This review provides some consolidation of the recent research findings, but much more research needs to be done in order to fully understand the purpose and importance of the proprioceptive sensory system.


Leg length inequality. Implications for running injury prevention.

Leg length inequality is a relatively common musculoskeletal malalignment related to structural, postural and environmental factors. The inequality is a plausible aetiological factor in the development of a variety of overuse injuries because it alters the magnitude and distribution of mechanical stress within the body. Leg length inequality has been linked with lower extremity stress fractures, low back pain, hip pain and vertebral disk problems of runners. The appropriateness of using inshoe lifts to reduce or eliminate the inequality has not been rigorously evaluated. Further research is needed to quantify the biomechanical effects of leg length inequality as it interacts with other factors related to running injury.


[Lissencephalia syndromes].

Lissencephaly is in most cases a genetic anomaly of the brain development with agyria and/or pachygyria. It causes severe psychomotor retardation and epilepsy, which is often resistant to therapy. Some patients with type-I lissencephaly show cranial and facial dysmorphism and a deletion of chromosome 17p13.3 (Miller-Dieker syndrome). The isolated lissencephaly sequence occurs without these features. Patients with type-II lissencephaly present additional malformations of the posterior fossa and of the eyes (Walker-Warburg syndrome) and in some cases muscular dystrophy (cerebro-oculomuscular syndrome). Lissencephaly can be suspected with a high probability by its typical EEG. It is proved by imaging techniques. Therapeutic success is limited, the life expectancy is strongly reduced.


[Progressive supranuclear palsy].

Progressive supranuclear palsy, first described as clinical entity by Steele, Richardson and Olszewski, is a degenerative disorder of the central nervous system. Besides progressive supranuclear oculomotor disturbances, other characteristic signs are pseudobulbar paresis, axial rigidity, gait disturbances and subcortical dementia. Misinterpretation in the early stage as Parkinson's disease is frequently seen. A causal therapy is still missing.


[Ischemic cerebrovascular seizure: when and how should one search for a cardiac embolism source?].

Cerebral embolism originating from the heart accounts for approximately 15 to 20% of ischemic strokes. By far the most important source for cardiac embolism is associated with atrial fibrillation; in these patients immediate anticoagulation with no further echocardiographic diagnostic is recommended. The majority of the remaining cardiac sources of embolism--they originate from the left ventricle and the valves--can be suggested by clinical signs. In these cases a documentation by echocardiography is indicated. In contrast, embolism originating from the left atrium is rare and commonly not detectable by simple clinical means. The semi-invasive transesophageal echocardiography is able to visualize atrial pathologies with a high accuracy, but this investigation should be performed routinely only in patients less than 45 years old with no evidence for cardiac disease.


[Cerebrovascular complications in cardiac surgery].

Mortality and physical impairment in patients undergoing cardiac surgery are to a large extent due to cerebro-vascular complications that are second in frequency only to cardiopulmonary incidents. In spite of the extracorporeal circulatory support as well as progress in cardiac surgery that have improved the perioperative conditions, neurologic complications mainly of embolic nature are still common after extracorporeal circulatory assistance.


[Assessment of cerebral autoregulation using transcranial Doppler sonography under lower body negative pressure].

A novel technique for transcranial Doppler sonographic assessment of cerebral autoregulation was tried out in 20 healthy volunteers, ten of them right-handed and ten left-handed. A fall in arterial blood pressure was produced through lower body negative pressure (LBNP) of -50 mmHg during 1 min. The Doppler shift signal of both middle cerebral arteries was recorded simultaneously and analyzed digitally to obtain mean Doppler shift frequency and Doppler signal power. Their product, as an index of volume flow, was calculated on-line. By positioning and coupling of the transducers and keeping the position of the head stable throughout the test, spurious readings due to the effects of gravity or head movement were excluded. With an average fall of mean arterial blood pressure of 10.3 +/- 7.7 mmHg, the TCD flow index as averaged over the entire period of LBNP was 103.6 +/- 19.5% of the value measured under atmospheric pressure, demonstrating a physiological autoregulation. In the right-handed subjects the flow index during LBNP was significantly higher on the right than on the left side. In only one of the ten right-handed individuals the side difference was reversed, while this was the case in five of the ten left-handed subjects.


Epidemiology of obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is the most common organic disorder of excessive daytime somnolence. In cross-sectional studies the minimum prevalence of OSAS among adult men is about one per cent. Prevalence is highest among men aged 40-65 years. The highest figures for this age group indicate that their prevalence of clinically significant OSAS may be 8.5% or higher. Habitual snoring is the most common symptom of OSAS (70-95%). The most significant risk factor for OSAS is obesity, especially upper body obesity. Other risk factors for snoring, and for OSAS, are male gender, age between 40 and 65 years, cigarette smoking, use of alcohol, and poor physical fitness. Upper airway obstruction with snoring or sleep apnea are commonly seen in children of all ages. Snoring is very common among infants and children with Pierre Robin syndrome and among infants with nasal obstruction. Snoring and obstructive sleep apnea are also very common in men with acromegaly. Many other syndromes or diseases exist in which the upper airway is narrowed. Prevalence of snoring and sleep apnea is increased in all such situations. It has been suggested that sleep apnea may be one mechanism contributing to sleep-related mortality. The prevalence of every night snoring seems to decrease after the age of 65. However, more than 25% of persons over 65 have more than five apneas per hour of sleep. It remains to be seen whether this finding has clinical significance. Partial upper airway obstruction, even without apneas, may influence pulmonary arterial pressure and may cause daytime sleepiness and some health consequences.(ABSTRACT TRUNCATED AT 250 WORDS)


From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness.

Some patients with excessive daytime sleepiness who do not present the features of obstructive sleep apnea syndrome (OSAS) present a sleep fragmentation due to transient alpha EEG arousals lasting between three and 14 seconds. These transient EEG arousals are related to an abnormal amount of breathing effort, indicated by peak inspiratory esophageal pressure (Pes) nadir. In the studied population, these increased efforts were associated with snoring. Usage of nasal CPAP, titrated on Pes nadir values, for several weeks eliminated subjective daytime sleepiness and improved Multiple Sleep Latency Test scores from baseline evaluations. Patients suspected of CNS hypersomnia should be asked about continuous snoring, and their clinical evaluation should include a good review of maxillo-mandibular and upper airway anatomy.


Neurobehavioral manifestations in obstructive sleep apnea syndrome before and after treatment with continuous positive airway pressure.

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent apneas during sleep, resulting in repetitive hypoxemic episodes and a constant interruption of the normal sleep pattern. Vigilance impairment and neuropsychological deficits are among the main symptoms seen in this condition. One of the major questions in this field concerns the reciprocal interactions between nocturnal hypoxemia, sleep disruption, excessive daytime sleepiness and cognitive deficits. Results of this study suggest that vigilance impairment is attributable mostly to nocturnal hypoxemia. However, in cognitive deficits, hypoxemia seems to play a major role in executive and psychomotor tasks, whereas attention and memory functions appear to be related to vigilance impairment. After treatment, hypoxemia-related deficits and some degree of sleepiness persist. These results raise the possibility of an irreversible anoxic central nervous system (CNS) damage in severe OSAS.


Sleep-related hemodynamics and hypertension with partial or complete upper airway obstruction during sleep.

Many different hemodynamic changes can be observed during obstructive apneas in the nocturnal sleep period. The most significant changes are observed whenever apneas occur in rapid succession. Systemic, pulmonary, and wedge pressure are modified. Many of these changes are mediated through cholinergic mechanisms. The mechanical effort of breathing against a partially or completely obstructed airway may also have an impact on hemodynamics. This impact must be dissociated from the impact of hypoxemia and blood gas changes. It has been questioned whether obstructive sleep apnea syndrome (OSAS) has any significant role in the development of 24-hour hypertension. In support of this theory, we found that tracheostomy does eliminate hypertension in obstructive sleep apneic children. In adults the issue is more complicated. Hypertension was eliminated in a subgroup of our patients treated with tracheostomy or nasal continuous positive airway pressure (CPAP), although the total group had no statistically significant blood pressure differences. Many variables that might dissociate treatment responders from nonresponders are not available. Hypertensive patients whose blood pressure normalized with OSAS treatment were significantly less overweight than the nonresponders in our series. Patients who remained hypertensive after treatment did, however, develop a normal circadian blood pressure trough during nocturnal sleep.


Sleep apnea syndromes (SAS) of specific etiology: review and incidence from a sleep laboratory.

Sleep apnea syndrome (SAS) results from modification in the control of respiration and of upper airway caliber during sleep. Although there is some overlap between central (CSAS) and obstructive (OSAS) sleep apnea syndromes, each syndrome has specific pathological associations. The first part of this review concerns the pathophysiology of OSAS, including periodic breathing and upper airway collapse. In the second part, each specific etiology is examined, and the respective contribution of anatomic narrowing and neuromuscular dysfunction of the upper airway is mentioned. Our experience with about 375 patients with sleep-related breathing disorders is also reported, with regard to the specific etiologies of CSAS and OSAS.


Chronic obstructive pulmonary disease and sleep apnea syndrome.

The term "overlap syndrome" was introduced by Flenley to describe the association of sleep apnea syndrome (SAS) with chronic obstructive pulmonary disease (COPD). Epidemiologic data on the prevalence of the overlap syndrome are not available, but the frequency of an associated COPD in SAS patients has been emphasized in almost all the studies analyzing the development of respiratory insufficiency in SAS patients. In a large series (n = 264) of unselected SAS patients who had undergone detailed pulmonary function tests, we observed an obstructive ventilatory defect (FEV1/VC < 60%) in 30 of 264 patients (11%). These patients had lower daytime PaO2 and higher PaCO2 than the other patients and they had higher resting and exercising pulmonary artery mean pressure (right heart catheterization was performed in 215 of 264 patients). We conclude that the risk of developing respiratory insufficiency and cor pulmonale is higher in overlap patients.


Clinical and therapeutic aspects of obstructive sleep apnea syndrome in infants and children.

Sleep related increases in respiratory resistive loads in infants and children may or may not be associated with complete obstruction, i.e. obstructive apneas. Nevertheless, important clinical symptoms, both nocturnal and diurnal, may be present and should be taken into consideration. A thorough investigation must be performed to select the most appropriate therapy.


Sleep apnea syndrome in the elderly.

Sleep apnea syndrome (SAS) is a well established sleep disorder with high morbidity and mortality. Patients are most often middle-aged men. SAS occurs in at least 1% of the adult population. Several studies have suggested that SAS is extremely frequent in the elderly, its prevalence ranging from 18 to 73% in this group. However, the generalization of these results to elderly cohorts is questionable because of several limitations of these studies, including lack of standard selection criteria, variation in recording techniques, the night to night variability of sleep apnea and the use of a moderate level of sleep disordered breathing (SDB) to define SAS (5 apneas per hour). The study best designed for valid extrapolation to the whole aged population estimates the frequency of SAS at 18%. However, most of these patients reported satisfactory sleep, and epidemiologic criteria for a causal association between SAS in the elderly and cardiovascular disease have not been satisfied. The conclusions of numerous studies dealing with impairment in cognitive function and SAS in the elderly are controversial. In fact, if the diagnostic threshold is increased from 5 apneas to 10 apneas plus hypopneas per hour, elderly SAS patients have more sleep disturbances, are more depressed and have cognitive deficits as compared to normal old persons. When an appropriate diagnostic index is used, SAS in the elderly resembles SAS described in the middle-aged population. In addition, a high apnea plus hypopnea index is an ominous predictor of mortality in the elderly population, and a very high level of SDB is an extremely significant risk factor for mortality during sleep phase in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)


Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers.

In a prospective study aimed at evaluating objectively the compliance with nasal continuous positive airway pressure (CPAP) treatment, 233 obstructive sleep apnea (OSA) (apnea index, > 10 apneas/hour) patients and 36 nonapneic snorers were studied. The compliance to treatment was measured by the mean rate of use of the CPAP device, obtained from a built-in time counter. The follow-up period was 874 +/- 48 in OSA patients and 675 +/- 83 in snorers. CPAP was proposed to all OSA patients but only to those snorers who felt improved after an initial laboratory night on CPAP. Nineteen OSA patients refused CPAP. Of the 214 OSA patients who accepted CPAP, 181 are still on treatment, with a mean daily rate of use of 5.6 +/- 0.1 hours (mean +/- SEM); 22 patients stopped CPAP after a variable period of time; 10 patients died and one acromegalic patient was considered cured after hypophysectomy for a pituitary adenoma. Depending upon the definition of acceptable compliance, the compliance rate in this group was between 77% and 89%. The mean rate of use was correlated with indices of disease severity (apnea index, apnea+hypopnea index, minimal SaO2 during sleep, daytime PaO2, pulmonary artery pressure). Thirty-six nonapneic snorers accepted CPAP. In this group, 26 are still on CPAP, with a mean daily rate of use of 5.4 +/- 0.5 hours; one patient died; one underwent uvolopalatopharyngoplasty without follow-up; and eight stopped CPAP. The compliance rate in this group was between 58% and 78%. This study shows that CPAP is reasonably accepted by OSA patients as well as by nonapneic snorers.(ABSTRACT TRUNCATED AT 250 WORDS)


Mechanisms of the effectiveness of continuous positive airway pressure in obstructive sleep apnea.

Nasal continuous positive airway pressure (NCPAP) is considered the most effective treatment of obstructive sleep apnea. Its beneficial effects are related to the normalization of breathing during sleep and to the prevention of nocturnal desaturations. NCPAP interacts with the pathophysiologic mechanisms of sleep apnea onset and with the consequences of these apneas. Upper airway patency is maintained with NCPAP by a pneumatic splinting effect while changes in lung volume and pre-apnea SaO2 level may be implicated in the improvement of apnea-related desaturations. An improvement in central chemosensitivity could account for the improvement in diurnal oxygenation observed with long term NCPAP therapy.


Respiratory monitoring in sleep apnea syndrome.

This review provides a critical analysis of current respiratory monitoring techniques in diagnosis of sleep apnea syndrome. The correct analysis of polysomnography requires knowledge of the limitations of the means of recording used. These limitations, for invasive and noninvasive techniques, are discussed in terms of calculation, differentiation and scoring of respiratory events. Aims and means are stated for monitoring and scoring in research as well as in clinical practice.


Evaluation of the upper airway in sleep apnea syndrome.

The upper airway is the final common site for abnormalities in respiratory control and neuromuscular function leading to sleep apnea. This review summarizes the information that pharyngeal assessment provides for understanding upper airway pathophysiology and selecting treatment. The applications and limitations of both static and dynamic techniques are examined in awake and sleeping patients. The effects of posture on the upper airway and the usefulness for predicting treatment efficiency are examined.


Assessment of uvulopalatopharyngoplasty for the treatment of sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) consists in the surgical removal of the uvula, part of the muscular portion of the soft palate and redundant palatal and pillar mucosa, and the tonsils. Since 1981, UPPP has been proposed for the treatment of sleep apnea syndrome. Polysomnographic studies have shown that in about half of the patients submitted to UPPP there is a 50% or greater reduction in apnea index. Attempts to identify presurgically those patients more likely to benefit from UPPP have yielded inconsistent results. Limited retrospective follow-up data suggest that UPPP does not modify the increased mortality associated with moderate and severe sleep apnea syndrome. Patients submitted to UPPP report subjective improvement, irrespective of the objective polysomnographic postsurgical results. It is suggested that polysomnographic evaluation of UPPP results should be mandatory; that any patient with 20 or more apnea/hypopneas per hour of sleep or sleep fragmentation after UPPP should be considered a treatment failure and be offered alternative therapy; and that UPPP should be performed only as part of prospective clinical trials including long-term follow-up.


Surgical alternatives to uvulopalatopharyngoplasty in sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) is the surgery most often performed for sleep apnea syndrome (SAS). However, good results with UPPP, demonstrated by polysomnography, have been reported in only 50% of cases. Failure of UPPP may be caused by: 1) bad management of the SAS, which is better treated in some patients with nasal CPAP than with surgery; and 2) an airway obstruction located not only at the palatopharynx (PP) level. Other surgical procedures to enlarge other sites of obstruction are described. Retro-tongue-base-pharynx (RTBP) surgery is emphasized, including mandibular advancement, hyoid bone suspension, and tongue base reduction. Maxillomandibular advancement is the most efficient technique but also the most complicated.


Alternative therapeutic approaches in sleep apnea syndrome.

A number of therapeutic alternatives to continuous positive airway pressure (CPAP) and surgery have been proposed to treat sleep apnea syndrome. Nasopharyngeal intubation may provide an immediate, simple and cost-effective means of bypassing upper airway obstruction during sleep. Tolerance is good in small children but is lower, between 30 and 40%, in adults. Clinical improvement is reported by more than half of the patients treated with this device and is confirmed by polysomnography. However, in most of these subjects, breathing during sleep is only partially corrected and sleep remains fragmented. Nasopharyngeal intubation should be proposed in infants, in patients who do not tolerate CPAP or as a therapeutic substitute for CPAP during holidays or traveling. The tongue retaining device and variants of orthodontic appliances have been proposed in order to increase upper airway patency. Tolerance is low, efficacy is usually incomplete and limited to patients with moderate forms of SAS, and long-term follow-ups are scarce. Sleep position training has been advocated as a means of reducing time spent in the supine position. Long-term efficacy has not been proven. Weight loss by caloric restriction or surgical procedures produces a variable improvement of sleep architecture and breathing during sleep. It should be proposed to all patients with SAS, as cure has been achieved in a few patients with the adjunction of weight loss and another treatment modality.


Ambulatory diagnosis of sleep-related breathing disorders.

Ambulatory diagnosis of sleep-related breathing disorders (SRBD) is necessary due to their high prevalence and to the limited capacities of sleep centers. Categories of SRBD which must be diagnosed and differentiated are defined. Indications for ambulatory diagnosis are given. A selection of systems on the market in Europe are given and described in terms of their parameters. The correct system for diagnosis in a specific patient must be selected according to the specific question. The issue of ambulatory diagnosis of SRBD has gained importance in Germany because beginning in spring 1992 physicians will be reimbursed if they continuously record respiratory signals, heart rate, oxygen saturation and movement in their patients and if they qualify by attending a one-week training course.


[Angiosarcoma of the breast: 4 case reports and review of the literature].

Four cases of angiosarcoma of the breast, including three previously unpublished, form the starting point for a brief descriptive review of this extremely rare but fearsome tumour which accounts for only 0.04 per cent of breast malignancies. The contrast between the initially totally benign clinical appearance of this sarcoma and the dramatic prognosis of its advanced or metastatic forms against which adjuvant chemotherapy remains of only relative usefulness, leads the authors to chiefly discuss a diagnostic approach likely to speed recognition (histological diagnosis) and treatment (simple mastectomy) of a tumour with two troublesome features: its powerful metastatic potential being matched only by its extreme rarity which may cause clinicians, radiologists and histopathologists to use valuable time.