[Can solid state Holter monitoring replace endomyocardial biopsy in patients with heart transplantation?]. Acute cardiac graft rejection after transplantation, the diagnosis of which is based on the findings of endomyocardial biopsy, is associated with a reduction in coronary reserve due to abnormalities of the microcirculation. But this reduction in coronary reserve cause silent myocardial ischaemia (SMI)? In order to assess the frequency of SMI and ventricular arrhythmias during rejection, 53 consecutive Holter recordings were performed in 32 patients (28 men, 4 women, average age 47 +/- 11 years) 11 months after transplantation and within 24 hours of endomyocardial biopsy. The recorder which was used (Monitor One TC) analysed the ST segment in 2 leads in real time: ST segment depression of more than 1 mm lasting over 40 ms, 0.08 s after the J point were considered to be diagnostic of myocardial ischaemia. Although the frequency of SMI is low and not specific for cardiac rejection, its duration was twice as long (80 mn vs 38 mn) in this condition. On the other hand, ventricular arrhythmias are common in cardiac rejection and correlated with its severity according to Billingham's classification (VES p = 0.045; doublets p = 0.035; non-sustained VT p = 0.006).


[Percutaneous ablation of atrioventricular junction by radiofrequency current in resistant atrial arrhythmia. Results of a series of 24 patients]. Catheter ablation of the atrioventricular junction may be proposed for the treatment of certain atrial arrhythmias resistant to antiarrhythmic therapy. One of the methods currently being evaluated uses radio-frequency energy which has certain advantages compared with direct current ablation because of the progressive and limited lesions it produces. This technique was used in 24 patients with atrial arrhythmias resistant to antiarrhythmic therapy. The radio-frequency energy was delivered without general anaesthesia with HAT 100 and 200 (OSYPKA) generators in the unipolar mode (average 17.4 watts) for an average period of 22.3 +/- 8 seconds. The catheter (8F USCI suction catheter in the first 18 patients and a 7F Polaris Mansfield, deflectable catheter with a large distal electrode in the remainder) was positioned at the nodo-hisian junction at a point where the two distal electrodes recorded a large atrial deflection and the smallest possible hisian potential. The conduction defects induced during the acute phase generally remain stable in cases of complete atrioventricular block and tend to regress in cases of incomplete atrioventricular block despite initial control of atrioventricular conduction. During follow-up (21 +/- 16 months), 14 patients (58%) remained in complete atrioventricular block, 4 patients (17%) had controlled atrioventricular conduction with an acceptable ventricular rate with associated previously ineffective antiarrhythmic therapy. Radio-frequency ablation was a failure in 6 patients (25%). There were no haemodynamic, rhythmic or ischaemic complications during the acute phase or during follow-up. These results suggest radio-frequency energy is a seductive alternative to direct current ablation for percutaneous modification of atrioventricular conduction in patients with refractory atrial arrhythmias. However, simple modulation of atrioventricular conduction gives aleatory results due to the tendency to regression during follow-up. On the other hand, complete atrioventricular blocks created by radio-frequency energy are generally definitive and are associated with a junctional escape rhythm which is usually stable.


[Left ventricular filling and left bundle branch block: an echocardiographic and radionuclide study]. Left bundle branch block changes the activation and haemodynamics of the left ventricle. In order to evaluate its consequences on left ventricular filling, the duration of the isovolumic relaxation period, the velocities and the integrals of the rapid and slow filling waves were recorded by Doppler echocardiography and the ejection fraction, the peak filling rate and its time of apparition were measured by gamma angiocardiography in 18 patients aged 55 +/- 9 years and 18 control subjects aged 53 +/- 9 years. Left bundle branch block was associated with a prolonged isovolumic relaxation period (104 +/- 14 vs 88 +/- 11 ms) a delayed and reduced peak filling rate and an increased atrial filling velocity at a heart rate comparable to that of control subjects (69 +/- 9 vs 72 +/- 8 beats/mn). Despite these changes in left ventricular relaxation and filling and a reduced ejection fraction (55 +/- 7 vs 61 +/- 6%, p < 0.01) cardiac output was not significantly decreased in left bundle branch block (4.9 +/- 1 vs 5.2 +/- 0.9 l/mn). Therefore, left bundle branch block interferes with left ventricular filling and ejection fraction without decreasing the resting enddiastolic volume.


[Prostaglandin E in vaginal smears--a possibility for sperm detection in azoospermia]. The identification of seminal traces is exceptionally difficult, if the semen of the assailant is azoospermic. The evident value of prostatic acid phosphatase (PAP) activity must be evaluated in such cases with caution. In a murder investigation of a 13 year old girl a positive PAP reaction was found in vaginal swabs and in her underpants. Spermatozoa could not be found. Using the gas-chromatographic method, described by Douse (1985) the presence of prostaglandin E could be demonstrated in the swabs as well as in the crotch of the underpants. The offender was found to be a man with azoospermia, who admitted intercourse but with the consent of the victim. The E prostaglandins are mainly synthesized in the vesiculae seminal and seen to be specific for semen. Swabs taken from mouth and rectum showed negative reactions for prostaglandins in this case. Prostaglandins could never be detected in vaginal swabs taken at least 7 days after intercourse. Conversely Douse could detect prostaglandins in swabs up to 58 hours after intercourse. Apparently the prostaglandin detection by Douse provides a suitable alternative besides to the quantitative and immunological PAP detection or the immunological detection of the protein p 30.


[Thrombi of the right heart. Value of thrombolytic therapy in mobile thrombi]. Seven patients with mobile right heart thrombi, 4 floating and 3 pediculated, were recensed between 1985 and 1990. Two patients were admitted for congestive cardiac failure (Group I) and 5 patients for pulmonary embolism (Group II). Both patients in Group I were treated with heparin without complications. In one case, the size of the thrombus decreased in 10 days whereas, in the second case, it disappeared within 8 days. In Group II, the first patient underwent successful thrombectomy. The other four patients were given thrombolytic therapy (UK = 2, rt-PA = 2) associated with appropriate doses of heparin. In the two patients given UK (3M units the first day followed by 1.2 M units per day for 4 days) the thrombus disappeared in the first 48 hours of treatment. One patient had a recurrent pulmonary embolism after 2 hours' treatment; both patients had a fall in haemoglobin of 3 cg/ml at the second day. The second patient died at the 5th day. In the two patients treated by rt-PA (100 mg/7 hours) the thrombus disappeared within 4 hours of starting therapy. One patient had a probable recurrent pulmonary embolism. Both patients had a fall in haemoglobin of 3 cg/ml at the 2nd day of treatment. Right heart thrombi are rare (168 cases in the literature of which 111 were mobile). The prognosis seems to be related to echocardiographic appearances: mortality of mural thrombi is about 4% compared with 50% in mobile thrombi. Very mobile "worm-like" masses are therapeutic emergencies because of the risk of embolism (about 68%).(ABSTRACT TRUNCATED AT 250 WORDS)


[Diastolic function of the left ventricle in aortic valve stenosis. Doppler echocardiography]. Doppler echocardiographic parameters of LV diastolic function (isovolumic relaxation time, E wave velocity, ratio of E/A wave velocities, mitral valve pressure half time) were compared to catheter data in 35 patients (average age 67 years) with pure or dominant aortic stenosis (mean gradient: 65 +/- 30 mmHg). The isovolumic relaxation time was prolonged in most patients (m = 103 +/- 23 ms) and seemed uninfluenced by any haemodynamic parameter. There was a positive correlation between pressure half time and ejection fraction (r = 0.41, p = 0.02) and a negative correlation with pulmonary capillary pressure (r = -0.61, p < 0.01). The E and E/A ratio were negatively correlated with the ejection fraction (r = -0.41 and -0.52) and positively correlated with pulmonary capillary pressure (r = 0.46 and 0.62). The Doppler parameters were independant of the patients' age, severity of stenosis and degree of left ventricular hypertrophy. Patients with normal pulmonary capillary pressure (< 15 mmHg, N = 19) had abnormal diastolic filling with low E wave velocities (71 +/- 28 cm/s) and E/A ratios (0.9 +/- 0.6) and prolonged half pressure times (96 +/- 37 ms). Conversely, patients with high pulmonary capillary pressures (> 15 mmHg, N = 16) had normal or high E wave velocities (107 +/- 31 cm/s) and E/A ratios (1.5 +/- 0.6) and normal or shortened isovolumic relaxation times (62 +/- 22 ms).(ABSTRACT TRUNCATED AT 250 WORDS)


[Proarrhythmic effects of antiarrhythmic drugs]. The proarrhythmic effects of antiarrhythmic drugs are complications which have been described over several decades but the mechanisms (reentry, increased automaticity, ectopic faci, induced repetitive activity, vagal or adrenergic triggers) and the predisposing factors (underlying cardiac disease, previous severe arrhythmia, metabolic disorders, ischaemia, etc...) have only recently been identified. The appreciation of their true frequency poses problems of methodology (mode of recruitment, therapeutic converse proof), of definitions and depends to a great extent on the methods of detection used. Their severity cannot be denied and has been demonstrated both in experience of isolated cases and in recent prospective studies, the conclusions of which must be interpreted critically. Proarrhythmic effects may be observed at atrial (vagal or sympathetic arrhythmias, 1/1 flutter, acceleration of atrial fibrillation in preexcitation syndromes), junctional (artificial unidirectional block created by the antiarrhythmic drug which may be very effective at higher dosages: biphasic effect) or ventricular (aggravation of ventricular extrasystoles, torsades de pointe, ventricular tachycardia/fibrillation) levels. It is curious that no antiarrhythmic drug seems to be statistically less exposed to this type of complication which may result from phenomena of toxicity or idiosyncrasy. Given the potential gravity measures must be taken to prevent this complication, by observing simple rules (respect of contraindication, use of progressive dosage regimens, avoidance of loading doses, elimination of predisposing factors and abstention from dangerous therapeutic associations) and by carefully following up high risk patients.


[Potential value of omega-3 polyunsaturated fatty acids in the prevention of atherosclerosis and cardiovascular diseases]. Several epidemiological studies have shown decreased cardiovascular mortality and a lower incidence of coronary artery disease in subjects with high dietary intakes of Omega-3 polyunsaturated fatty acids. It has since been shown that Omega-3 fatty acids have a number of beneficial effects in the prevention of atherosclerosis in man: reduction of blood pressure, modifications of lipoprotein metabolism, modifications of haemostasis (increased bleeding time and reduced platelet aggregation), decreased plasma fibrinogen, modifications of the metabolism of arachidonic acid and its derivatives (decreased thromboxane and leukotriene synthesis, increased prostacyclin synthesis). Therefore, Omega-3 polyunsaturated fatty acids have several beneficial effects on the presumed mechanisms of atherogenesis and/or its complications: they could represent an original and seductive solution to the problem of prevention of cardiovascular disease.


[Peripheral calcific embolism after percutaneous mitral valvuloplasty]. The authors report a case of calcific embolization after percutaneous mitral valvuloplasty. The nature of the embolism was confirmed by anatomopathological examination after popliteal embolectomy. This complication would appear to be extremely rare but represents an additional risk in patients with calcific mitral stenosis.


[Right intra-atrial extension of hydatid cyst mimicking cardiac thrombosis. Apropos of a case]. The authors describe an unusual case of hydatid cyst inserted in the inferior vena cava and extending into the right atrium. The transoesoesophageal echocardiographic appearances were similar to those of a thrombus: the tumour was very mobile, echogenic, polylobular with a cord-like pedicle in the inferior vena cava. The pathological examination revealed a ruptured hydatid cyst. The mass and its insertion were not visible on CT scan or cavography. Transoesophageal echocardiography would therefore seem to be a very useful diagnostic method for tumours arising in the inferior vena cava and extending into the right atrium.


[Cardiovascular manifestations of Cogan syndrome. Apropos of a case]. The authors describe a case of Cogan's syndrome in a patient with ulcerative colitis complicated by several cardiovascular manifestations including bilateral coronary ostial stenosis, rapidly progressive aortic regurgitation and aneurysm of the thoracic aorta, thrombosis of the common iliac artery and pericardial symphysis. This rare form of inflammatory arteritis, the diagnosis of which is usually made on the finding of associated ocular and auditory involvement, is distinct from other types of angiitis by the predisposition to severe cardiovascular complications which influence the vital prognosis. The differential diagnosis with more common collagen diseases with cardiovascular complications is discussed.


The influence of congo red on the cell wall and (1----3)-beta-D-glucan microfibril biogenesis in Saccharomyces cerevisiae. Congo red was applied to growing yeast cells and regenerating protoplasts in order to study its effects on wall biogenesis and cell morphogenesis. In the presence of the dye, the whole yeast cells grew and divided to form chains of connected cells showing aberrant wall structures on both sides of the septum. The wall-less protoplasts in solid medium with the dye exhibited an abnormal increase in volume, regeneration of aberrant cell walls and inability to carry out cytokinesis or protoplast reversion to cells. In liquid medium, the protoplasts synthesized glucan nets composed mainly of thin fibrils orientated at random, whereas normally, in the absence of dye, the nets consist of rather thick fibrils, 10 to 20 nm in width, assembled into broad ribbons. These fibrils are known to consist of triple 6/1 helical strands of (1----3)-beta-D-glucan aggregated laterally in crystalline packing. The thin fibrils (c. 4 to 8 nm wide) can contain only a few triple helical strands (c. 1.6 nm wide) and are supposed to be prevented from further aggregation and crystallization by complexing with Congo red on their surfaces. Some loose triple 6/1 helical strands (native elementary fibrils) are also discernible. They represent the first native (1----3)-beta-D-glucan elementary fibrils depicted by electron microscopy. The effects of Congo red on growth and the wall structure in normal cells and regenerating protoplasts in solid medium can be explained by the presence of a complex which the dye forms with (helical) chain parts of the glucan network and which results in a loss of rigidity by a blocked lateral interaction between the helices.


Nucleotide sequence of the rpoN (hno) gene region of Alcaligenes eutrophus: evidence for a conserved gene cluster. The nucleotide sequence of the rpoN gene, formerly designated hno, and flanking DNA regions of the aerobic hydrogen bacterium Alcaligenes eutrophus has been determined; rpoN codes for the RNA polymerase sigma factor sigma 54 involved in nitrogen regulation and diverse physiological functions of gram-negative bacteria. In A. eutrophus hydrogen metabolism is under control of rpoN. The Tn5-Mob insertion in a previously isolated pleiotropic mutant was mapped within the rpoN gene. The derived amino acid sequence of the A. eutrophus RpoN protein shows extensive homology to the RpoN proteins of other organisms. Sequencing revealed four other open reading frames: one upstream (ORF280) and three downstream (ORF130, ORF99 and ORF greater than 54) of the rpoN gene. A similar arrangement of homologous ORFs is found in the rpoN regions of other bacteria and is indicative of a conserved gene cluster.


The role of tungstate and/or molybdate in the formation of aldehyde oxidoreductase in Clostridium thermoaceticum and other acetogens; immunological distances of such enzymes. Besides Clostridium thermoaceticum and C. formicoaceticum other resting acetogenic clostridia such as C. aceticum and C. thermoautotrophicum and to a lesser extent non-clostridial acetogens such as Butyribacterium methylotrophicum and Eubacterium limosum were able to reduce propionate to propanol at the expense of carbon monoxide or formate. Methylviologen usually increased the reduction rate. Ten microM molybdate in the growth medium decreased this capability for C. thermoaceticum but increased it or had no effect for the other organisms. Ten microM tungstate in the growth medium increased the aldehyde oxidoreductase activity in all organisms. Crude extracts of C. thermoaceticum cells grown in the presence of 10 microM or 1 mM molybdate showed by ELISA the same or even a 4 fold concentration of aldehyde oxidoreductase in the latter case. However, the enzymic activity was very low in both cases. Omission of dithionite in the growth medium diminished the antigen by a factor of about 8. The immunological distance between the enzyme from C. thermoaceticum and C. thermoautotrophicum was rather low but very large to C. formicoaceticum and undeterminably large to the other organisms.


Electron microscopic examination of sporulation-deficient mutants of the fission yeast Schizosaccharomyces pombe. A homothallic haploid strain of the fission yeast Schizosaccharomyces pombe initiates sexual reproduction (mating, meiosis and sporulation) in nitrogen-free sporulation medium. Cellular fine structures of eleven sporulation-deficient mutants (spo2, spo3, spo4, spo5, spo6, spo13, spo14, spo15, spo18, spo19 and spo20) of S. pombe in sporulation medium were examined by serial section-electron microscopy. The striking features of these spo mutants were: 1) the disappearance of the spindle pole bodies (SPBs) after the second meiotic division, and 2) the accumulation of unorganized structures. Based on histochemical staining, these structures were presumably unorganized spore wall precursors. In some mutants (spo3, spo5, spo6, spo19 and spo20), diploid zygotes contained four spore-like bodies which had walls similar to complete spore walls but failed to enclose any nuclei. After completion of the second meiotic division the nuclei were abnormally distributed in zygotic diploid cells. In the spo5, spo13, spo14, spo15 and spo19 mutants, the nuclei remained attached to each other. In spo5 and spo19, the inner membrane of the nuclear envelope was separated, but its outer membrane was shared by two sister nuclei. These observations suggest that the spo+ gene products play important roles in spatial and temporal organization of cellular structures during ascospore development.


Transformation of synthetic pyrethroid insecticides by a thermophilic Bacillus sp. Employing a mineral salts medium containing Tween 80 as the primary carbon source, a strain of Bacillus stearothermophilus was isolated which was able to hydrolyse selected second and third-generation pyrethroids to non-insecticidal products. Of a range of pyrethroid insecticides the trans-isomer of permethrin was the most readily transformed by this microbial isolate, whilst flumethrin was the least. 3-Phenoxybenzoic acid and the respective halovinyl or haloacid moieties were detected as the major hydrolytic products of the pyrethroids. It is believed that 3-phenoxybenzoic acid was formed from 3-phenoxybenzyl alcohol which was not however detected as an intermediate in these systems. 3-Phenoxybenzoic acid was further transformed to 4-hydroxy-3-phenoxybenzoic acid. A potential metabolic pathway has been described.


2-Hydroxyglutaryl-CoA dehydratase from Fusobacterium nucleatum (subsp. nucleatum): an iron-sulfur flavoprotein. Anaerobically prepared cell-free extracts from Fusobacterium nucleatum contain 2-hydroxyglutaryl-CoA dehydratase with a specific activity of 20 nkat mg-1. The enzyme was purified 24-fold to a specific activity of 480 nkat mg-1 by anion exchange chromatography, gel filtration and chromatography on Blue-Sepharose. The activity of the purified enzyme was strictly dependent on the reductant Ti(III)citrate and stimulated 25-fold by 0.15 mM ATP and 5 mM MgCl2. ATP is hydrolysed to ADP during incubation with 2-hydroxyglutaryl-CoA dehydratase in the presence or absence of the substrate. The enzyme is extremely sensitive towards oxygen and is inhibited by 10 microM chloramphenicol, 10 microM 2,4-dinitrophenol or 0.15 mM hydroxylamine. The pure enzyme consists of three subunits alpha (49 kDa), beta (39 kDa) and gamma (24 kDa) in approximately equal amounts. In this respect the enzyme differs from the related 2-hydroxyglutaryl-CoA dehydratase from Acidaminococcus fermentans and lactyl-CoA dehydratase from Clostridium propionicum both of which are composed of only two subunits with sizes comparable to those of alpha and beta but require an additional protein for activity. The relative molecular mass of the native enzyme of about 100 kDa suggests a trimeric alpha beta gamma-structure. The homogeneous enzyme contains riboflavin (0.5 mol/112 kDa), iron and sulfur (3.5 mol/112 kDa each). Polyclonal antibodies directed against the 2-hydroxyglutaryl-CoA dehydratase from A. fermentans did not crossreact with cell free extracts or purified dehydratase from F. nucleatum. A comparison of the N-terminal amino acid sequences of the dehydratase subunits from A. fermentans and F. nucleatum, however, showed some similarities in the beta-subunits.


Characterization of a carbofuran-degrading bacterium and investigation of the role of plasmids in catabolism of the insecticide carbofuran. A bacterium capable of using the carbamate insecticide carbofuran as a sole source of carbon and energy, was isolated from soil. The ability to catabolise carbofuran phenol, produced by cleavage of the carbamate ester linkage of the insecticide, was lost at very high frequency when the bacterium was grown in the absence of carbofuran. Plasmid analyses together with curing and mating experiments indicated that the presence of a large plasmid (pIH3, greater than 199 kb) was required for the degradation of carbofuran phenol.


[Clinical and lesion-related bases of alcoholic brain damage]. Alcohol-induced brain damage is known since long, with classical descriptions of lesions. There is no constant correlation between them and any of the clinical presentations of chronic intoxication. New neuroimaging techniques, neuropsychology and basic investigation have supplied with new data. The so-called alcoholic dementia and its possible reversibility are major issues of this problem. This paper reviews radiological, pathological, vascular and neuropsychological studies related to this point.


[Visual constructive deficits and coma depth]. The present study has the purpose of relating the capacities of visual retention with the Benton Visual Retention Test and the level of coma depth, which is measured with the GCS (Glasgow Coma Scale). 31 subject suffering cranioencephalic damage admitted to the intensive care unit (ICU) have been studied. GCS scores were obtained during their stay in the intensive care unit and the Benton Visual Retention Test was administered after hospital discharge. The procedure followed consists in comparing the performance of subjects with higher GCS scores to subjects with lower values when executing administration. A of form C of BVRT. We could conclude as follows: firstly that BVRT is a useful tool to detect the existence of brain damage; secondly, indexes of brain damage presence with BVRT are: a low figure in correct design, more errors, less errors in distortion and rotation; more errors in the left visual hemifield. Thirdly, the depth of coma is a good prognosis index on BVRT execution and in consequence of visuo-constructive abilities.


[Experimental model of Parkinson disease: mechanisms and anatomo- pathological characteristics of MPTP neurotoxicity]. MPTP administration induces a fairly selective lesion of substantia nigra dopaminergic neurons both in animals and humans. This characteristic of MPTP has led to the best available model of Parkinson's disease and neuronal degenerations. MPTP toxicity is actually provoked by MPP+ which results after oxidation by MAO-B. Possible mechanism of action of MPP+ include: 1) Mitochondrial lesion. 2) Free radicals generation. 3) Trapping of MPP+ by highly melanized neurons. This article reviews the mechanisms of toxicity by MPTP and its neuropathological characteristics.


Treatments of depression and the functional capacity to work. This study evaluated the effects of antidepressants and psychotherapy on work impairment in depressed patients. Original databases from 10 published treatment studies were compiled and analyzed (N = 827). Functional work impairment was common at baseline, manifested by unemployment (11%) or on-the-job performance problems (absenteeism, decreased productivity, interpersonal problems, 44%). Generally, work outcomes were good when treatment was symptomatically effective, but the trajectories of work restoration and symptom remission were different, with work recovery appearing to take considerably longer. Relapse was an important determinant of long-term occupational outcome, particularly for seriously ill patients for whom relapse meant rehospitalization or other profound social disruption. Affective impairment was distinguished from functional impairment, with the former characterizing milder depression and the latter characterizing moderate to severe depression. Some methodological recommendations are discussed.


[Benign evolution of a spontaneous vermian hematoma using conservative treatment]. Spontaneous intracerebellar haematomas are a relatively unusual cause of haemorrhagic stroke. The uncommon variety of vermian haematomas (5%) represents a serious diagnostic and treatment challenge and its outcome is generally poor, being the result of rapid elevation of intracranial pressure and brainstem compression. A rare case of spontaneous vermian haematoma with benign course without surgery is reported, including the results of neuroimaging tests.


Five-year outcome for maintenance therapies in recurrent depression. After conducting a randomized, 3-year maintenance trial in 128 patients with recurrent depression who had responded to combined short-term and continuation treatment with imipramine hydrochloride and interpersonal psychotherapy, we asked those individuals who survived the 3-year trial receiving active medication (with or without psychotherapy) to continue in a 2-year additional randomized trial of active medication vs placebo. The question was whether maintaining antidepressant medication at the dosage used to treat the acute episode beyond 3 years would continue to provide a significant prophylactic effect compared with medication discontinuation after the 3 years of effective maintenance treatment. Survival analysis demonstrated a highly significant continued prophylactic effect for active imipramine hydrochloride treatment maintained at an average dose of 200 mg. We conclude that active imipramine treatment is an effective means of preventing recurrence beyond 3 years and that patients with previous episodes less than 2 1/2 years apart, therefore, merit continued prophylaxis for at least 5 years.


[Nuclear syndrome of the oculomotor nerve caused by a mesencephalic infarction confirmed by MRI]. The nuclear syndrome of the third nerve was first described in 1981. It has the very characteristic disturbance of an ophthalmoplegia with complete ipsilateral third nerve palsy associated with paresis of elevation in contralateral eye. This particularly presentation is due to the innervation of the superior rectus which comes mainly from the contralateral oculomotor nucleus. As associated signs were described contralateral cerebellar and or pyramidal syndromes, uni or bilateral parasympathetic disfunction and sometimes gaze disorders. The etiology es usually a vascular damage (ischemic most frequently) located in mesencephalon. We report on a case of a 60 years old man who developed acute nuclear ophthalmoplegia of the third right nerve accompanied with cerebellar and pyramidal syndrome and focal asterixis in left extremities. MRI showed an ischemic lesion in right paramedial mesencephalic territory with extension to the ipsilateral thalamic region. Pyramidal and cerebellar syndromes and asterixis disappeared in a few weeks, while ophthalmoplegia remained unchanged. Semiologic characteristics and anatomic basis of the nuclear oculomotor syndrome which allow to make the differential diagnosis between this syndrome and intra-axial fascicular disturbances of the third nerve (Weber, Claude and Benedikt syndromes) are discuss.


Cognitive therapy and pharmacotherapy for depression. Singly and in combination. Cognitive therapy and imipramine hydrochloride tricyclic pharmacotherapy, each singly and in combination, were compared in the treatment of nonpsychotic, nonbipolar depressed outpatients. One hundred seven patients were randomly assigned to 12 weeks of active treatment; 64 patients completed the full course of treatment. Rates of attrition were high but not differential. Cognitive therapy and pharmacotherapy did not differ in terms of symptomatic response, either in the primary analyses or in secondary analyses restricted to more severely depressed outpatients. Initial severity did predict response within pharmacotherapy alone, but not within cognitive therapy. Combining cognitive therapy with pharmacotherapy did not markedly improve response over that observed for either modality alone, although such nonsignificant differences as were evident did favor the combined treatment. Two patients died as a consequence of suicide attempts, both of which involved study medication.


Course of depressive symptoms over follow-up. Findings from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. We studied the course of depressive symptoms during an 18-month naturalistic follow-up period for outpatients with Major Depressive Disorder treated in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. The treatment phase consisted of 16 weeks of randomly assigned treatment with the following: cognitive behavior therapy, interpersonal therapy, imipramine hydrochloride plus clinical management (CM), or placebo plus CM. Follow-up assessments were conducted at 6, 12, and 18 months after treatment. Of all patients entering treatment and having follow-up data, the percent who recovered (8 weeks of minimal or no symptoms following the end of treatment) and remained well during follow-up (no Major Depressive Disorder relapse) did not differ significantly among the four treatments: 30% (14/46) for those in the cognitive behavior therapy group, 26% (14/53) for those in the interpersonal therapy group, 19% (9/48) for those in the imipramine plus CM group, and 20% (10/51) for those in the placebo plus CM group. Among patients who had recovered, rates of Major Depressive Disorder relapse were 36% (8/22) for those in the cognitive behavior therapy group, 33% (7/21) for those in the interpersonal therapy group, 50% (9/18) for those in the imipramine plus CM group, and 33% (5/15) for those in the placebo plus CM group. The major finding of this study is that 16 weeks of these specific forms of treatment is insufficient for most patients to achieve full recovery and lasting remission. Future research should be directed at improving success rates of initial and maintenance treatments for depression.


The course of depression in adult outpatients. Results from the Medical Outcomes Study. To compare the course of depression during a 2-year period in adult outpatients (n = 626) with current major depression, dysthymia, and either both current disorders ("double depression") or depressive symptoms with no current depressive disorder. Depressed patients visiting 523 clinicians (mental health specialists and general medical providers) were identified using a two-stage screening procedure including the Diagnostic Interview Schedule. The course of depression was assessed in 2 follow-up years with a structured telephone interview based on the format of the Diagnostic Interview Schedule. Baseline severity of depressive symptoms was greatest in patients with double depression, but initial functional status was poor in those with dysthymia with or without concurrent major depression. Patients with dysthymia had the worst outcomes, those with current major depression alone had intermediate outcomes, and those with subthreshold depressive symptoms had the best outcomes. Even the latter group, however, had a high incidence (25%) of major depressive episode over 2 years. Initial depression severity and level of functional status accounted for more explained variance in outcomes than did type of depressive disorder. The findings emphasize the poor prognosis associated with dysthymia even in the absence of major depression; the prognostic significance of subthreshold depressive symptoms; and the clinical significance of assessing level of severity of symptoms as well as functional status and well-being, regardless of type of depressive disorder.


The course of major depression in the offspring of depressed parents. Incidence, recurrence, and recovery. The 2-year course, first onset (incidence), recurrence, and recovery of major depression in 174 offspring at high and low risk for major depression were studied. A variety of predictors of course were examined, including parental diagnosis, demographic and clinical characteristics of the family and offspring, comorbidity and social functioning in offspring, and family risk factors. The 2-year incidence rate was 8.5%. All of the incident cases of major depression occurred in offspring of depressed parents. Additional predictors of incidence were a preceding diagnosis of conduct disorder and subclinical symptoms of depression. The recurrence rate results are tentative because of the small sample. The 2-year recurrence rate was 16.1%. Predictors of recurrence were a previous comorbid diagnosis of dysthymia or problems in social functioning. By the end of 2 years, the majority of offspring (87%) had recovered. The mean number of weeks to recovery was 54 in the offspring of depressed parents and 23 in the offspring of nondepressed parents. Offspring with an onset of major depression at age 13 years or younger, who were exposed to divorce in the family or who had been exposed to more than one parental depressive episode, had significantly more protracted times to recovery. We conclude that there are different predictors of incidence of major depression, its recurrence, and time to recovery in offspring, and that parental depression has an impact on the course in offspring.


Differential relapse following cognitive therapy and pharmacotherapy for depression. Patients successfully treated during a 3-month period with either imipramine hydrochloride pharmacotherapy, cognitive therapy, or combined cognitive-pharmacotherapy were monitored during a 2-year posttreatment follow-up period. Half of the patients treated with pharmacotherapy alone continued to receive study medications for the first year of the follow-up. All other patients discontinued treatment at the end of the acute treatment phase. Patients treated with cognitive therapy (either alone or in combination with medication) evidenced less than half the rate of relapse shown by patients in the medication--no continuation condition, and their rate did not differ from that of patients provided with continuation medication. It appears that providing cognitive therapy during acute treatment prevents relapse. Whether this preventive effect extends to recurrence remains to be determined.


Time to recovery, chronicity, and levels of psychopathology in major depression. A 5-year prospective follow-up of 431 subjects. The course of illness of 431 subjects with major depression participating in the National Institute of Mental Health Collaborative Depression Study was prospectively observed for 5 years. Twelve percent of the subjects still had not recovered by 5 years. There were decreasing rates of recovery over time. For example, 50% of the subjects recovered within the first 6 months, and then the rate of recovery declined markedly. Instantaneous probabilities of recovery reflect that the longer a patient was ill, the lower his or her chances were of recovering. For patients still depressed, the likelihood of recovery within the next month declined from 15% during the first 3 months of follow-up to 1% to 2% per month during years 3, 4, and 5 of this follow-up. The severity of current psychopathology predicted the probability of subsequent recovery. Subjects with moderately severe depressive symptoms, minor depression, or dysthymia had an 18-fold greater likelihood of beginning recovery within the next week than did subjects who were at full criteria for major depressive disorder. Many subjects who did not recover continued in an episode that looked more like dysthymia than major depressive disorder.


Depressive symptoms as relative and attributable risk factors for first-onset major depression. Using longitudinal data from a community study of 9900 adults drawn from four sites in the United States and interviewed twice, 1 year apart, we investigated the predictors of first-onset major depression. Using odds ratios to estimate relative risk, we found that persons with depressive symptoms, compared with those without such symptoms, were 4.4 times more likely and persons with dysthymia were 5.5 times more likely to develop a first-onset major depression during a 1-year period. The lifetime prevalence rate for depressive symptoms was 24%. The attributable risk is a compound epidemiologic measure that reflects both the relative risk associated with depressive symptoms (4.4) and the prevalence of exposure to that risk (24%). It is a useful measure to document the burden of a risk to the community, and it was determined to be greater than 50%. Thus, more than 50% of cases of first-onset major depression are associated with prior depressive symptoms. The high prevalence of depressive symptoms in the community and their strong association with first-onset major depression make them important from a public health perspective. Because depressive symptoms are often unrecognized and untreated in clinical practice, we conclude that their identification and the development of effective treatments could have implications for the prevention of major depression.


Stability of psychiatric diagnoses. An application to the affective disorders. In the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression study, data were collected on 2226 first-degree relatives of 612 probands. A second, "blind" reassessment of all relatives was attempted 6 years after the initial evaluation. We report on a final sample of 1629 relatives assessed twice using the Schedule for Affective Disorders and Schizophrenia-Lifetime version. We summarize methods for using stability of diagnosis to model the relationship between clinical covariates and the probability of being a true case. Moreover, we define an index of caseness that can be used to narrow the criteria for who is a case. Of those positive for major depressive disorder at initial evaluation, 74% were positive (on a lifetime basis) at follow-up (ie, were stable). There is a gradient: 48% of those who had three symptoms and no treatment were stable, compared with 96% of those with eight symptoms and treatment. For major depressive disorder, we found the caseness index for those with lifetime mania more severe than that of nonbipolar patients, with those who had hypomania being intermediate. A hierarchical analysis indicated that bipolar I tends to be diagnosed as schizoaffective-manic across occasions, and vice versa. This is consistent with the prior familial analyses that suggest these two diagnoses be combined into a single bipolar phenotype. The analysis for major depressive disorder indicates that caseness appears to represent quantitative, rather than qualitative, differences, with no natural cutoff to identify distinct subgroups. Finally, we discuss implications including utility in genetic analyses, estimation of incidence or prevalence allowing for diagnostic error, and examination of cohort effects.


The impact of transplantation on the clinical laboratory. Experience at the University of Nebraska with bone marrow and liver transplantation. The number of both bone marrow and solid organ transplantation programs has increased significantly during the past several years. The implementation of these programs and their growth have had a significant impact on the clinical laboratories that are involved in the support of these programs. Between 1983 and 1985, two major organ transplantation programs were implemented at the University of Nebraska Medical Center, Omaha. The clinical laboratories at the University of Nebraska Medical Center have seen a 217% increase in procedure volume and a 165% increase in full-time equivalents during an 8-year period from 1983 to 1991 as a result of these programs. The laboratory procedures that are performed on patients who are undergoing transplantation currently generate approximately $9 million in charges per year. In the present article, I discuss the effect of bone marrow and liver transplantation programs on the entire laboratory and individual laboratory sections.


An alternate origin for the placental isoenzyme of alkaline phosphatase. By means of an electrofocusing technique, the serum specimens of pregnant women routinely revealed three bands of alkaline phosphatase (ALP) that were released by placental syncytiotrophoblast, germ cell (ovary), and fetal intestine at pl of 4.73, 4.65, and 4.55, respectively. When defining reference ranges for ostensibly healthy persons of all decades of age and investigating patients with elevated total ALP activity, we found the isoenzyme at pl 4.73 to be above the established reference range in some nonpregnant women and in men. Evidence suggests that T lymphocytes from whole blood or in vivo tissue were the origin of this pl 4.73 ALP band; the isoenzyme being released during cell lysis, in cellular turmoil from any cause, or when active cell division occurs. A designation of lymphocyte ALP is proposed for this ALP band that is observed in a broad group of diseases associated with abnormal lymphocyte function.


Naked megakaryocyte nuclei as an indicator of human immunodeficiency virus infection. Compact, lobulated megakaryocyte nuclei, apparently denuded of cytoplasm (naked nuclei), have been reported to be markedly increased in the bone marrow of persons infected with human immunodeficiency virus (HIV). We have confirmed this observation and have developed a useful diagnostic index, the naked nucleus ratio, to characterize the bone marrow of individuals who are infected with HIV. The naked nucleus ratio, calculated as the average number of naked nuclei per high-power field divided by the average number of intact megakaryocytes per high-power field, has a sensitivity of 97.9% and a specificity of 96.4% for patients with HIV infection. In our patients with a 62.6% prevalence of HIV infection, the predictive value of a positive test was 97.9% and the predictive value of a negative test was 96.4%. An increase in the naked nucleus ratio above 10%, without specific changes in the bone marrow, should raise or may confirm the suspicion of HIV infection.


Comparison of hemoglobin and red blood cell distribution width in the differential diagnosis of microcytic anemia. In a total group of 415 subjects (100 normal controls, 115 with iron deficiency anemia, 100 with the alpha-thalassemia trait, and 100 with the beta-thalassemia trait), the following indexes were analyzed: hemoglobin distribution width, red blood cell distribution width (RDW)-coefficient of variation, and RDW-SD. The hemoglobin distribution width and RDW-coefficient of variation were examined with a laser light scattering system (Technicon H1), whereas the RDW-SD was determined with an impedance autoanalyzer (Sysmex M-2000). All of these parameters helped, to some extent, in the differential diagnosis of microcytic anemia. However, our data suggested a low RDW-SD might provide significantly more value in differentiating thalassemia traits from iron deficiency anemia, as well as from normal controls, while the hemoglobin distribution width gave no help in the differential diagnosis between iron deficiency anemia and the beta-thalassemia trait.


Distribution of tritiated cocaine in selected genital and nongenital organs following administration to male mice. To determine the distribution of cocaine administered to male mice in selected extragenital and genital organs and to investigate its possible binding to sperm. Twenty-seven sexually mature virus-free albino male mice were used in various experiments whereby following intravenous injection of tritiated cocaine hydrochloride, radioactivity was determined in several extragenital and genital organs, as well as sperm. Radioactivity was detected in all of the organs that were tested, and the highest concentrations per milligram of tissue were found in the kidney and epididymis. Removal of the sperm from the epididymis significantly reduced the radioactivity of the organ. The spermatozoa that were isolated on glass filters showed a linear correlation vs radioactivity (r = .93). Radioactivity is distributed to several organs, including the genital tract, and is found in association with sperm after in vivo administration of tritiated cocaine. These results may explain the mechanism underlying a male-mediated teratogenesis, which has been observed in animals that were exposed to cocaine, and they raise a possibility that the spermatozoa may carry cocaine into the oocyte during fertilization.


Vascular proliferation of the thyroid. A complication of fine-needle aspiration. Fine-needle aspiration (FNA) of the thyroid has a low morbidity rate, with hematoma formation being the most commonly encountered complication. We describe two cases of exuberant vascular proliferation within the thyroid gland, one resembling a cavernous hemangioma and the other with similar changes but with areas of papillary endothelial hyperplasia. Both lesions occurred in patients with a recent history of FNA prior to the thyroidectomy procedure. The vascular proliferation was interpreted as organizational changes in a hematoma secondary to the FNA. These cases, in conjunction with a recent case of Masson's vegetant intravascular hemangioendothelioma complicating thyroid FNA, expand the literature on vascular proliferations that may develop subsequent to thyroid FNA.


Intrapulmonary neuroglial heterotopia.

Intrapulmonary neuroglial heterotopia. Nonteratomatous intrapulmonary neuroglial heterotopia not associated with birth trauma or frank vascular embolization has been described rarely. This article briefly reviews the literature, and presents two additional cases of intrapulmonary neuroglial heterotopia. We found 14 cases in the literature. Twelve of these cases had central nervous system disruption, where neuroglial elements were in direct contact with amniotic fluid. Several hypotheses have been proposed, including fetal aspiration of detached neural fragments within amniotic fluid, neural crest migration defects, and vascular embolization with implantation. Of our two cases, one represents the first occurrence where central nervous system abnormalities were secondary to mechanical disruption, rather than to a primary neural tube defect. Our second case represents the youngest documented occurrence (17 weeks gestation) of intrapulmonary neuroglial heterotopia. Additionally, immunohistochemical studies were performed on these lesions, the results of which favor their neural origin. We present these findings and suggest they support the aspiration mechanism for neuroglial heterotopia in lung tissue.


Postcapillary venule-like transformation of peritubular capillaries in acute renal allograft rejection. An ultrastructural study. To describe ultrastructural changes in renal peritubular capillaries during acute allograft rejection, biopsy specimens from five allografts with acute rejection were studied electron microscopically and compared with control specimens. The thickness, cross-sectional area, and luminal circumference of capillary endothelium were estimated morphometrically. Thickening of endothelial cells, loss of fenestration, increase in endothelial cell organelles, increased adherence and passage of lymphocytes and monocytes, and defects in the endothelial lining were demonstrated. The luminal circumference representing the size of the capillary was not changed. A balloonlike fragmentation of endothelial cells was sometimes observed around lymphocytes, suggesting cytotoxic injury to capillaries. The observations indicate that during rejection-induced endothelial activation, peritubular capillaries exhibit postcapillary venule-like transformation that enhances the influx of inflammatory cells into the kidney allograft.


Primary smooth-muscle tumors of the ovary. A clinicopathologic study of four leiomyomas and two mitotically active leiomyomas. A series of six primary ovarian smooth-muscle tumors were studied. Four were ordinary leiomyomas and two were neoplasms with prominent mitotic activity, which we designated mitotically active leiomyomas. The patients' ages ranged from 42 to 76 years (median, 50.5 years). In five of six patients, synchronous leiomyomas of the uterus were also present. In three patients, the ovarian tumor was an incidental finding. The maximum dimension of the ovarian tumors ranged from 0.3 to 20.0 cm (median, 3.0 cm). Three of the tumors originated in the hilar region, one on the cortical surface, and in two the exact location within the ovary could not be determined. Follow-up was available on all six patients. None developed local recurrence or metastasis from their ovarian tumor, including the two patients with mitotically active leiomyoma whose postoperative follow-up intervals were 3.8 and 7.7 years.


Hodgkin's disease presenting as spontaneous splenic rupture. Hodgkin's disease presenting as spontaneous splenic rupture is rare. A 46-year-old man with a 4-week history of fever, chills, and night sweats developed sudden abdominal pain and hypotension. At surgery, an enlarged, ruptured spleen with a nodular surface was found. Histologically, there was diffuse infiltration of the red pulp by mixed-cellularity Hodgkin's disease with patchy involvement of the white pulp. The histopathologic findings in the three previously reported cases are all dissimilar to this. These differences most likely represent rupture occurring at different stages of splenic infiltration by Hodgkin's disease.


Granular cells in a cellular neurilemmoma. In this article, we describe a case of a cellular neurilemmoma with focal granular cell elements. The Schwann cells showed S100 and Leu-7 immunoreactivity. The granular cells were periodic acid-Schiff-positive, diastase resistant with strong S100 immunoreactivity. Electron microscopy showed electron dense, heterogeneous granules in the granular cells and interdigitating processes and elongated nuclei of the Schwann cells. Although many granular cell tumors are believed to be derived from Schwann cells, neoplasms with both elements are rarely presented.


The application of backpropagation neural networks to problems in pathology and laboratory medicine. Neural networks are a group of computer-based pattern recognition technologies that have been applied to problems in clinical diagnosis. This review focuses on one member of the group of neural networks, the backpropagation network. The steps in creating a backpropagation network are (1) collecting adequate training facts, (2) choosing the specific network structure, (3) training the network, and (4) cross-validating the trained network. The first published applications of backpropagation networks to problems in pathology and laboratory medicine have appeared recently. These applications are in the areas of image analysis and interpretation of laboratory results, and they demonstrate the feasibility of the approach.


[Aqueous chloramine T solutions as disinfectants: chemical composition, reactivity and toxicity]. In aqueous solutions of Chloramine T (CAT), caused by dissociation, hydrolysis and disproportionation processes, seven different kinds of molecules emerge (HOCl, OCl-, R-NCl-, R-NHCl, R-NCl2, R-NH2, and R-NH- [R = CH3-C6H4-SO2]). Their equilibrium concentrations have been calculated using an iteration process (polynom of 4th degree) as a function of cCAT (0.003-10%) and pH (0-14): The (absol.) concentration of "free chlorine" ([HOCl] + [OCl-]) is surprisingly low showing a maximum concentration of HOCl in the whole concentration and pH range of only 2 . 10(-7) moles/l (0.014 ppm). The relative equilibrium concentrations of the N-chlorinated toluene sulfonamide species R-NCl-, R-NHCl, and R-NCl2, virtually alone responsible for the oxidizing and by this also disinfecting properties, owing to the extremely low concentration of free chlorine, are influenced in the concentration range relevant for practice (greater than 0.1%) only by the pH-value: At pH greater than 7 the whole oxidation capacity is present as R-NCl- (pH 7: 99.6%; pH 8: 99.96%), while at pH less than 3 it is formed by R-NHCl and R-NCl2.(ABSTRACT TRUNCATED AT 250 WORDS)


[Local anesthetics. 99. Synthesis and local anesthetic actions of alkoxyphenylcarbamates]. Within the framework of studying the influence of alterations of the connecting chain in the group of local anaesthetics a series of 24 compounds of 1-propoxymethyl-2-(1-pyrrolidinyl), 2-(1-piperidino)-, and 2-(1-perhydroazepinyl)-ethyl esters of o- and m-alkoxyphenylcarbamic acid were prepared. Studied compounds show a high index of relative local anaesthetic activity as compared to the standards cocaine and procaine, at a relatively low acute toxicity.


Synthesis and antimicrobial activity of 3-(substituted-phenyl)-sydnones. 3-(3 or 4-Acetylphenyl)-sydnones 7, 8 have been synthesized by formation of the glycines 3, 4, followed by nitrosation to 5, 6 and cyclization with acetic anhydride to sydnones. Sydnone derivatives carrying chalcone moieties 15, 16 were prepared by formation of the chalcone analogues 11, 12 through condensation of the glycines 3, 4 with the appropriate aldehydes, followed by the reactions applied for the preparation of 7, 8. The sydnone derivatives were screened for antimicrobial activities.


Pyrrylphenylethanones related to cathinone and lefetamine: synthesis and pharmacological activities. The synthesis of various pyrrylphenylethanones resembling cathinone and lefetamine is described starting from 2-chloro-1-(1-methyl-1H-pyrrol-2-yl)-2-phenylethan-1-one. Some derivatives showed good antinociceptic activity, comparable to that of morphine. The neuropsychopharmacological profile of title compounds has been also studied to explore their action on C.N.S.


New indole and triazino[5,4-b]indol-4-one derivatives: synthesis and studies as inotropics and inhibitors of blood platelet aggregation. New triazino[5,4-b]indol-4-one derivatives carrying amino groups in position 3 were synthetized and tested as inotropic agents and inhibitors of platelet aggregation. 2h, 2p, 5p, and 6g are the most active as inotropic agents. Compounds were tested as inhibitors of platelet aggregation induced by adenosine 5'-diphosphate (ADP) and arachidonic acid (AA) (guinea pig whole blood). 2k, 2p, 5o, 6d, 6m, and 6o are the most active as inhibitors of the platelet aggregation induced by AA. 6d, 6h, and 6o are most active compounds also in the aggregation induced by ADP. Radioimmunoassay studies, following AA induced aggregation, measuring thromboxane B2 (TXB2) and prostaglandin E2 (PGE2) were carried out on compounds 2b, 2d, 2f, 2g, 2h, 2i, 2k, 2m, 2o, 2p, 2r, 5i, 5j, 5k, 5r, and 5f, which inhibit platelet aggregation induced by AA. None of the compounds tested turned out to be selective inhibitors. Compounds 2h and 2p showed both inotropic and platelet aggregation inhibiting activity.


[Actions of new iminium compounds on bacteria and fungi. 27. Synthesis of 1-n-decyl-2-phenyl-3-(n-alkylthiomethyl)- and 1-n-decyl-2-phenyl-3-(n-alkoxymethyl)imidazolium chlorides]. The imidazolium compounds 1-3 were prepared by quaternization of 1-decyl-2-phenylimidazole with the pertinent chloromethyl-n-alkyl ethers. 1-3 were tested for their antibacterial and antimycotic efficacies.


New cardiotonic agents related to amrinone: synthesis of 1,2-dihydro-5-arylpyridin-2-ones. For development of new cardiotonic agents a series of 5-aryl-3,4-dihydropyridin-2(1H)-ones, related to amrinone have been prepared from methylquinolines, 2-arylacetic acid or 3-arylethanones by direct aminomethylenation and subsequent condensation-cyclization with malonamide and cyanacetamide in classic basic media or phase-transfer catalysis, in good to excellent yields. Preliminary pharmacological assays have shown that these compounds, especially 5h and 5i, have a remarkable cardiotonic effect and present a selective inhibition of PDE-III/PDE-I isolated from cat heart.


Synthesis and antiprotozoal properties of 1,2,6-thiadiazine 1,1-dioxide derivatives. The synthesis and spectroscopical data of 1,2,6-thiadiazine 1,1-dioxides, designed as antiprotozoal agents, are reported. The in vitro trichomonacidal and trypanocidal activities of new compounds and their precursors were evaluated against Trichomonas vaginalis and Trypanosoma cruzi. The chemoprophylactic activity on mice treated with blood infected with T. cruzi and their mortality percentage were tested. Compounds 2 and 8b show a higher chemoprophylactic activity and lower mortality percentage than Nifurtimox used as reference drug.


Aminopeptidase inhibitory properties and analgesic activity of (2S,3R)-3,7-diamino-2-hydroxy-heptanoic acid containing tripeptide analogues of the N-terminal tripeptide of probestin. (2S,3R)-3,7-Diamino-2-hydroxy-heptanoyl-Leu-Pro-OH [(2S,3R)-DAHHA-Leu-Pro-OH, 4], analogue of the N-terminal tripeptide of probestin, has been synthesized, and tested as inhibitor of AP-B, Leu-AP, AP-M, and enkephalin-degrading APs, and as analgesic. In order to establish structure-activity relationships the dipeptide (2S,3R)-DAHHA-Pro-OH (5) and the tripeptide (2S,3R)-DAHHA-Ala-Pro-OH (6) were also prepared. Compounds 4 and 6 were potent and selective inhibitors of enkephalin-degrading APs and showed a prolonged antinociceptive effect.


Bioavailability study of two different verapamil formulations. Relative bioavailability and bioequivalence of two oral verapamil preparations were investigated (dosage 80 mg, film-coated tablets as reference, dragées as test formulation). The clinical study was performed in a 2-period-cross-over design with 16 male healthy volunteers (mean age 28.8 +/- 3 years). The active metabolite norverapamil was included in the investigation. To assess bioequivalence several pharmacokinetic characteristics (i.e. AUC(o-oo), Cmax, tmax) were taken into account. Shortest 90% confidence intervals were calculated based on parametric (ANOVA, ANOVAlog) and non-parametric (Wilcoxon, Mann-Whitney) statistical tests. A positive decision for bioequivalence was accepted if the confidence intervals did not exceed the limits of 80-120% for AUC and 70-130% for Cmax. A mean relative bioavailability of 127% for the test preparation was found. Thus, bioavailability of the dragées is marked higher than bioavailability of the film-coated tablets.


Applying psychometric criteria to functional assessment in medical rehabilitation: III. Construct validity and predicting level of care. A discriminant analysis was performed using Rasch ability estimates derived from four Patient Evaluation and Conference System (PECS) subscales, to distinguish among the functional independence and impairment profiles exhibited by patients admitted into any of three levels of medical rehabilitation delineated by the National Association of Rehabilitation Facilities (NARF): (1) inpatient hospital, (2) atypical nursing home (intermediate), or (3) day program. Two discriminant functions accounted for 91% and 9% of the between-group variance, respectively. Cross-validated classification of patients into one of the three levels of care, based on discriminant function scores, produced 75% correct classification; a 66% improvement over the percentage of correct classification likely by chance alone. Results support the construct validity of the PECS subscales and indicate they may be useful in validating clinically-based admission decisions among three of the levels of care promulgated by NARF.


Predictors of family functioning one year following traumatic brain injury in children. This study examined changes in family functioning and predictors of family outcome during the year following traumatic brain injury (TBI). The families of 94 children with TBI (mild = 50, moderate = 25, severe = 19), ages six to 15, were consecutively enrolled from two regional medical centers. Family interview ratings and standard measures of family and child functioning were completed three weeks after injury (measuring preinjury status), as well as three and 12 months. Two-thirds of families had moderate to good preinjury global functioning and coping resources, but more than half exhibited high levels of stress and at-risk family relationships. No significant preinjury differences by injury severity were seen on any measure. Whereas few changes in family functioning were observed over the year in the mild or moderate groups, greater deterioration occurred in the severe group. From one third to one half noted moderate to severe strain in 13 problem areas often seen in individuals with TBI. Preinjury family global functioning, however, was more strongly predictive of 12-month family functioning (R2 = .38 to .68) than was injury severity (R2 = .05 to .09). In four out of five outcome areas assessed at 12 months, preinjury status in each area was the strongest single predictor. Preinjury coping was the best predictor of stress. Families at risk can be identified and need ongoing support for optimal functioning.


Predicting return to work in traumatic brain injury using assessment scales. This study compared two frequently used brain injury assessment scales with a comprehensive functional scale in their capability to predict return to work in a traumatic brain injured population. Fifty-seven consecutive admissions to an inpatient brain injury program were rated at admission and discharge using the following scales: Patient Evaluation and Conference System (PECS), Disability Rating Scale, and Levels of Cognitive Functioning Scale. Their relative accuracy in predicting return to work or school up to 26 months after the injury was assessed using hierarchical logistic regression analysis. In each analysis, return to work/school was the dependent variable. The independent variables were initial status and discharge status on each rating scale. Overall these scales predicted return to work with 73.5% to 84.4% accuracy. Total PECS and PECS Cognition scores were the most accurate predictors. Analysis of incorrect predictions revealed the importance of additionally tracking the social factors of substance abuse, family/community support and financial need to return to work.


The treatment of agitation during initial hospitalization after traumatic brain injury. Agitation after traumatic brain injury is disruptive for patient care, distressing, and difficult to treat. The use of propranolol has been advocated to control agitation after brain injury. It reportedly lacks some of the deleterious cognitive and emotional effects of other medications and physical restraints. This study was designed to test if propranolol is effective in reducing agitated behavior. Subjects had traumatic closed-head injury treated at a combined Level I Trauma Center and Rehabilitation Center. Twenty-one subjects met the criteria of agitation and were treated with propranolol or placebo in a double-blind fashion. The intensity of agitation was significantly lower in the treatment group although the number of episodes were similar. The use of restraints was also significantly lower in the treatment group. The results support the effectiveness of propranolol in reducing the intensity of agitation during the initial hospitalization after closed-head injury.


Communicating with families of rehabilitation patients about "do not resuscitate" decisions. Resuscitation discussions can elicit potent emotional reactions from both health care providers and consumers. In rehabilitation settings, decision making grows more difficult if decisions must be sought from family members or proxies of incompetent patients. There is ample room for emotions and lack of clarity to lead to dissatisfaction and heightened distress. This paper outlines legal, ethical, and psychological factors that must be managed if clear communication between health care providers and families is to occur. Issues are discussed that can clarify thinking at each stage of the communication process.


Rehabilitation status in multiple handicap. The Edinburgh Rehabilitation Status Scale (ERSS) was applied to 129 attenders at a day center for physical disability. All of the attenders had significant neurological impairment dating from birth or from infancy. Fifty-nine of the subjects (46%) had been diagnosed on conventional grounds as having mental handicap as well as physical disability. ERSS scores were compared with Barthel Index scores in all subjects and with PULSES profile in 50 subjects (27 physical disability alone, 23 combined with mental handicap). The ERSS scores clearly demonstrated significant differences in the level of disablement between the two groups in all four subscales as well as in total scores; the Barthel scores showed differences in self-care and total scores, and, to a lesser extent, in mobility. PULSES failed to differentiate the groups except in one of its subscales. The ERSS is a sensitive index of overall function and is useful in highlighting the additive effect of mental handicap and physical disability, a difference which may not be apparent when other assessment scales are used.


Coronary risk in spinal cord injury: assessment following a multivariate approach. A group of 96 men with spinal cord injury was studied to find out if patients with spinal cord injury were at an increased risk of coronary heart disease. A multivariate approach based on data produced by the Framingham study was used to estimate the probability of developing coronary artery disease within six years. Data obtained from the 96 patients were compared with data obtained from 96 nontrained, able-bodied men matched according to age. The results of this study suggest that patients with spinal cord injury show a risk of coronary artery disease similar to that estimated in non-trained, age-matched, able-bodied individuals. The risk increases with age, but it is of the same order as that found in the normal population and does not appear to be related to the duration of the disease. The results are inconclusive in regard to the level of the lesion as an independent factor of risk.


Psychosocial adjustment of post-poliomyelitis ventilator assisted individuals. The effect of severe disability, tracheostomy, and ventilator use on psychosocial functioning, gainful employment, life satisfaction, and perceived well-being were studied for a population of 395 ventilator assisted post-poliomyelitis individuals (PVAIs). Standard psychosocial survey instruments and other general questioning were used. Two-hundred-seventy-three physically intact health care professionals served as controls. They were surveyed about their own life satisfaction and perceived well-being and were asked to judge how severely disabled ventilator assisted individuals would respond to such questioning. The relative distress associated with ventilator use was also evaluated in a similar manner. Fifty six of 380 responding PVAIs (14.7%) expressed dissatisfaction with their lives in general. This compares with 8.5% of the controls and 7% of a previously studied general population. The controls significantly underestimated the patients' life satisfaction and well-being scores and significantly overestimated the relative hardship associated with ventilator use. The post-polio individuals using noninvasive methods of assisted ventilation were also significantly more satisfied with their lives than were those ventilated via tracheostomy. Fifty-seven of 148 (39%) individuals married and 165 of 395 (42%) individuals were gainfully employed during long-term ventilator use. We conclude that many severely disabled post-poliomyelitis ventilator users lead productive lives. The vast majority have a positive affect and are satisfied with life. Noninvasive ventilatory support alternatives may lend to greater life satisfaction for these individuals than ventilation delivered via an indwelling tracheostomy. Health care professionals may significantly underestimate their patients' satisfaction with life and this may have a bearing on patient management.


Attention and arousal: basic science aspects. Disorders of attention are common after a variety of insults to the central nervous system. At present, treatment of these disorders is rarely based on a theoretical understanding of the neuroanatomy, neurophysiology, psychology, or psychopharmacology of attention. This article reviews the current state of knowledge of the mechanisms of attentional function and dysfunction, attempting to integrate findings across different types of research. In a subsequent article, the implications of these findings for clinical practice will be discussed.


A patellar-tendon-bearing orthosis used in pediatric burn rehabilitation. Burn rehabilitation in children presents a difficult challenge. Hypertrophic scar formation is accelerated in this population due primarily to the growth of normal surrounding tissue. Many patients who develop burn wound contractures of the foot and ankle are rendered nonambulatory. We describe a pediatric patients who developed fixed bilateral equinovarus deformities secondary to thermal injury. A patellar-tendon-bearing orthosis was fabricated for this patient to unload the foot-ankle complex with major weight bearing forces at the patellar tendon and tibial condyles. Through the incorporation of this orthosis with a full therapeutic rehabilitation program, the patient was able to ambulate independently using a rolling walker. We recommend the use of the patellar-tendon-bearing orthosis for those pediatric burn victims who develop foot-ankle contractures to allow for ambulation until such time as additional, more aggressive treatment is tolerated, or on a more permanent basis, if necessary.


Prenatal exposure to diethylstilbestrol (DES): childhood play behavior and adult gender-role behavior in women. Data from lower mammals suggest a masculinizing or defeminizing influence of pre- or perinatal diethylstilbestrol (DES) exposure on various aspects of the sex-dimorphic behavior (including juvenile rough-and-tumble play) of genetic females. However, three previous studies on childhood play and adult gender-role behavior in human females have led to ambiguous results. In a follow-up study of 60 women with prenatal exposure to DES and 26 controls, we used psychometrically well-designed multi-item scales based on self-report inventories for the assessment of these aspects of behavior. No effects of DES could be demonstrated. We conclude that, at the doses studied, prenatal DES exposure in human females has not led to behavioral masculinization or defeminization of childhood play and adult gender-role behavior.


Partnership after induced abortion: a prospective controlled study. To study the social and psychological consequences of induced abortion on the relationship between the pregnant woman and her partner, 92 patients seeking a socially indicated abortion, who had a stable partner at the time of abortion, were interviewed. Standardized psychological measures were used to assess their partnerships before abortion and on follow-up 1 year later. A control group of 92 patients (matched for age, marital status, duration of partnership, number of children, and educational background), drawn from a larger sample of women using safe contraceptive methods, completed the same psychological measures. Prior to abortion, partnerships in the study group showed considerably more conflicts and were less harmonious than in the control group. One year after the abortion, the number of separations in the study group was not significantly higher than in the control group, nor were there any remaining qualitative differences in the partnerships of either group. When separations occurred, they had been more frequently initiated by women in the study group than in the control group.


Sexual and aggressive motives in sexually aggressive college males. The relative contributions to sexual aggression of general sexual and aggressive motives and their respective inhibitory factors were compared. One hundred forty-three university males responded to self-report measures of sexual and aggressive drives, sex and hostility guilt, social desirability response bias, and history of coercive sexuality. With the effects of social desirability controlled, the only predictor of sexual aggression was Sex Guilt, which predicted level of force used but not intimacy of the sexual act obtained.


Do sex-linked behaviors in children influence relationships with their parents? When relationships are found between parents' and children's behaviors it is usually assumed the parents' behaviors produced those of the children. Forty-four young adult males and 36 young adult females reported the degree to which they showed various sex-linked behaviors and feelings of same versus opposite sex identity in childhood, and adolescence, and currently. These behaviors accounted for up to 57% of the variance of measures of the quality of relationships with parents. In men, opposite-sex-linked behaviors and identity correlated most strongly with current negative parental and particularly paternal relationships. They also correlated strongly with negative paternal relationships in childhood. Some sex-linked behaviors and sex identity items in men correlated positively with maternal overprotection in childhood and adolescence. Correlations between women's sex-linked behaviors and sexual identity items and their parental relationships were weaker but more consistently negative. As in men, opposite-sex-linked behaviors and identity in women correlated most strongly with current negative paternal relationships. The pattern of the associations and the finding that many opposite-sex-linked behaviors in subjects' childhood correlated most strongly with negative parental relationships in early adult life suggest that the parents' feelings could be partly a response to, rather than totally causal of, the subjects' sex-linked behaviors.


Sustaining passion: eroticism and safe-sex talk. It is axiomatic that communicating effectively is important for good sexual relations. In light of the AIDS epidemic and the necessity for safe-sex practices, the topic of caution and prevention is an emerging and critical discourse for the sexual encounter. Yet if this discourse is not to defy passion but rather complement it, then the study of sexual linguistics must be grounded within the realm of erotic reality. Three themes of eroticism and their implications for sexual interaction are explored in this paper: identity, context, and danger. Linguistic and relational constraints for enacting such a discourse are identified, accompanied by a critique of the treatment of erotic discourse in educational programs and the media.


Normocalcemic hyperparathyroidism. Biochemical and symptom profiles before and after surgery. Patients with normocalcemic hyperparathyroidism represent a diagnostic and therapeutic challenge. It is unclear to what extent these patients benefit from surgery in terms of correction of their serum chemistry abnormalities and their symptoms. We studied 142 patients: 23 with normocalcemic hyperparathyroidism (serum calcium levels below 2.62 mmol/L), 35 with intermittent hypercalcemia, and 84 with hypercalcemic hyperparathyroidism. Serum chemistry analyses and a standardized questionnaire of symptoms were completed before and after surgery. Overall, patients in the normocalcemic group reported a similar frequency of preoperative symptoms; had a similar reduction in postoperative symptoms; and had a similar normalization of serum calcium, parathormone, and phosphate levels as those in the two control groups. This study indicates that factors other than elevated serum calcium levels are in large part responsible for the symptoms of hyperparathyroidism and that these patients benefit from operation.


Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases. We reviewed our experience from 1979 to 1990 with 160 cases of transhiatal esophagectomy for carcinoma of the lower esophagus and cardia to evaluate trends in patient selection, management, and outcome. Patients treated in the past 6 years (n = 110) and those treated before 1985 (n = 50) were similar in terms of age and sex distribution, medical history, and weight loss. The majority of tumors seen were adenocarcinoma, with patients in the latter group having significantly lower stages. Significant decreases in anesthetic time, units of blood transfusions, chest tube insertions, length of postoperative ventilation, incidence of postoperative pneumonia, and length of hospital stay were seen during the past 6 years. Wound infections increased significantly during the same period. The decrease in the 30-day mortality rate from 6% to 0.9% was not significant. Survival rates did not differ between groups, with overall rates of 62%, 40%, and 21% at 1, 2, and 5 years, respectively.


An evaluation of two methods of limb salvage in extremity soft-tissue sarcomas. Between 1983 and 1990, 38 sequential patients with stage II to III soft-tissue sarcoma of the extremities, as defined by the American Joint Committee on Cancer, were treated. Eighteen patients were treated with intra-arterial doxorubicin hydrochloride, limb salvage surgery, and radiation (group A). Twenty patients in group B were treated with cisplatin, isolated limb perfusion, limb salvage surgery, and radiation. The study was not randomized, but all patients were treated prospectively using one of the two protocols. The two groups were similar demographically and had similar lengths of survival without disease. There was only one local recurrence in the series, and this occurred in a group B patient who underwent perfusion with the lowest dose of cisplatin. Regional perfusion with either intra-arterial doxorubicin hydrochloride or cisplatin combined with limb salvage surgery and postoperative radiation are highly effective in preventing local recurrences and preserving functional extremities in patients with soft-tissue sarcoma. There was no difference in results between these two methods.


Prospective trial of supranormal values as goals of resuscitation in severe trauma. We prospectively tested the effect of the early postinjury attainment of supranormal values of cardiac index (> or = 4.52 L/min per square meter), oxygen delivery (> or = 670 mL/min per square meter), and oxygen consumption (> or = 166 mL/min per square meter) on outcome in traumatized patients with an estimated blood loss of 2000 mL or more. The goals in control patients were to attain normal values for all hemodynamic measurements. During the 6-month period, 33 protocol patients and 34 control patients with similar vital signs, estimated blood losses, and severity of injuries were enrolled in the study. Eight (24%) protocol patients died, while 15 (44%) control patients died. The protocol patients had fewer mean (+/- SEM) organ failures per patient (0.76 +/- 1.21 vs 1.59 +/- 1.60), shorter stays in the intensive care unit (5 +/- 3 vs 12 +/- 12), and fewer mean days requiring ventilation (4 +/- 3 vs 11 +/- 10) than did the control patients (P < .05 for each). We conclude that attaining supranormal circulatory values improves survival and decreases morbidity in the severely traumatized patient.


Long-term results of treatment of Budd-Chiari syndrome with portal decompression. Thirty-three patients with Budd-Chiari syndrome were studied for 1 to 19 years following portal decompression. All had ascites, hepatomegaly, abnormal liver function, angiographic demonstration of inferior vena cava and/or hepatic vein occlusion, and biopsy specimens showing intense hepatic congestion and necrosis. When thrombosis was confined to hepatic veins (20 patients), side-to-side portacaval shunt resulted in 95% operative survival, 90% prolonged survival, permanent shunt patency, relief of ascites, reversal of liver dysfunction, and reversal or improvement of hepatic lesions. When thrombosis involved the inferior vena cava, mesoatrial shunt (eight patients) was unsatisfactory because of a 63% mortality rate from liver failure due to shunt thrombosis. In contrast, a new procedure consisting of combined portacaval and caval-atrial shunts (five patients) has been highly successful, with 100% survival, shunt patency, relief of ascites, and reversal of pathologic abnormalities.


Aortoenteric fistulas.

Aortoenteric fistulas. During an 11-year period ending in December 1991, 36 patients with aortoenteric fistulas were assessed and treated. Twenty-five patients (69%) had previously undergone aortic reconstruction with Dacron grafts, and 11 (31%) had spontaneous aortoenteric fistulas. Of the 25 patients with secondary fistulas, 14 (56%) had undergone aortic aneurysmal rupture or multiple aortic vascular reconstructions. Preoperative diagnosis was established in only 13 (36%) of 36 patients. Remote bypass preceding removal of the infected arterial prosthesis had the least morbidity and mortality. Three primary fistulas were found in unusual locations: aortocolonic, aortobronchial, and aortoesophageal. The patient with the aortoesophageal fistulas was the fifth survivor described in the literature. The overall mortality was 56%. A positive preoperative blood culture predicted a poor outcome. There were four amputations, there due to infection of the extra-anatomical bypass. Prompt directed assessment to ensure appropriately staged operative intervention should improve survival.


The ultrasonic dissector facilitates laparoscopic cholecystectomy. The ultrasonic dissector disrupts tissues in proportion to their fluid content by ultrasonically induced cavitational forces. Since sturdy tissues are spared, the instrument tends to follow tissue planes and to dissect fat and other soft tissues selectively. We performed a prospective, randomized, controlled trial in 73 patients comparing the safety and efficacy of a prototype ultrasonic dissector with that of electrosurgery and laser during laparoscopic cholecystectomy. Randomization was as follows: ultrasonic dissector, 37 patients; electrosurgery, 21 patients; and laser, 15 patients. The results were not different with respect to patient characteristics, amount of blood loss, technical difficulties, length of hospital stay, or return to work. Subjectively, the ultrasonic dissector was thought to be of special value in isolating the hilar structures, particularly when they were edematous or embedded in fat. The ultrasonic dissector disintegrated the fat, which was rapidly cleared up the suction channel, allowing the cystic duct and artery to be bared with less risk of injury. We concluded that the ultrasonic dissector has unique attributes that contribute to the ease and safety of laparoscopic cholecystectomy.


Protective effect of anisodamine on cultured bovine pulmonary endothelial cell injury induced by oxygen-free radicals. Anisodamine, a Chinese traditional medicine herb, has been used for treatment of adult respiratory distress syndrome effectively, but little is known about its mechanism. We attempted to investigate if anisodamine could protect bovine pulmonary endothelial cell injury induced by exogenous oxygen-free radicals that were generated by xanthine/xanthine oxidase or opsonized zymosan-stimulated polymorphonuclear leukocytes. Results showed that with the addition of xanthine/xanthine oxidase into cultured bovine pulmonary endothelial cells, production of malondialdehyde and release of lactate dehydrogenase in supernatant increased, and synthesis of prostacyclin decreased. Damaged cellular membranes were revealed by scanning electron microscopy. The same was true for the addition of opsonized zymosan-stimulated polymorphonuclear leukocytes. While treatment with anisodamine greatly attenuated all of the above-mentioned parameters, results showed that (1) cultured bovine pulmonary endothelial cells could be damaged by oxygen-free radicals, (2) anisodamine had a protective effect on this injury as effective as that of superoxide dismutase and catalase, and (3) the membrane-stable action might contribute to the mechanism of protective effect against this injury.


Is preoperative parenteral nutrition necessary for patients with predominantly ileal Crohn's disease? We reviewed 46 consecutive patients with Crohn's disease predominantly affecting the ileum who specifically underwent right-sided ileocolectomy with primary anastomosis. All had a primary ileocolic anastomosis done by suture in a single-layer closed fashion. Of these 46 patients, 19.6% had overt intra-abdominal sepsis, 30.4% had prior surgery, and 95.7% were taking corticosteroid drugs just before their operation. The mean (+/- SE) age was 31.5 +/- 2.0 years. The serum albumin level was less than 35 g/L in 93.5% of patients; all had a hematocrit value less than 0.36, and 80.4% lost more than 15% of their normal body weight. No patient received parenteral nutrition either preoperatively or postoperatively. No change in the preoperative, intraoperative, or postoperative approach to treating patients with predominantly ileal Crohn's disease occurred during the 10-year period of review. There was a 2.2% incidence of perioperative complications (one superficial wound infection) and a 6.5% incidence of late (>1.49 months) complications (two suture sinuses and one wound abscess unassociated with a fistula). Our findings suggest that preoperative parenteral nutrition is unnecessary in the majority of patients with predominantly ileal Crohn's disease specifically undergoing right-sided ileocolectomy and primary ileocolic anastomosis.


Intraoperative irradiation in resected carcinoma of the pancreas and portal vein. We developed a new method that provides a wide retroperitoneal irradiation field for patients with cancer of the pancreas in whom a long invaded portal vein is resected during intraoperative radiotherapy. This method involves the use of a venous bypass with a heparinized catheter that does not require systemic anticoagulation or a pump. Anastomosis is completed after intraoperative radiotherapy. Mean (+/- SD) duration of the venous bypass was 3.0 +/- 1.5 hours (range, 2.0 to 6.6 hours), during which no abnormalities of systemic blood pressure, heart rate, and electrocardiographic activity and no signs of congestion of the intestines were observed. Eleven patients were treated with this method, and no complications ascribed to intraoperative radiotherapy or venous bypass were found. We recommend this method as safe and simple for expanding the irradiation field for intraoperative radiotherapy in patients with pancreatic cancer in whom the portal vein is resected.


Significance of wall thickness in symptomatic gallbladder disease. One hundred cases of patients who underwent urgent cholecystectomy after presenting with symptoms of acute or subacute gallbladder disease were retrospectively reviewed. Sixty patients had pathologically proved acute cholecystitis, and 40 had chronic cholecystitis alone. One patient had an incidental gallbladder carcinoma, and four had global gangrene of the gallbladder. Focal ischemia, transmural hemorrhage, or focal necrosis (indicating more severe disease) was present in 19 patients. Fifty-four percent of patients had thin-walled gallbladders. Among patients with more severe acute disease, 56% had thin walls. Conversely, 24% of thin-walled gallbladders and 22% of thick-walled gallbladders had evidence of focal necrosis or gangrene. We conclude that gallbladder wall thickness, although demonstrable on preoperative ultrasound examination in all patients, does not correlate directly with severity of disease or pathologic findings.


Complement activation and polymorphonuclear neutrophil leukocyte elastase in sepsis. Correlation with severity of disease. Complement activation is necessary for an adequate immune and inflammatory response to infections. Activation releases anaphylatoxins that cause vasodilation, increase vascular permeability, and trigger release of polymorphonuclear neutrophil leukocyte (PMN) lysosomal enzyme and oxygen radicals. Under normal circumstances, an orderly progression of such events has a beneficial antimicrobial effect. The same mechanism, however, when uncontrolled, may damage host tissues. To provide information about the clinical importance of such events in sepsis, different complement parameters (C3, C4, and the desarginated forms of C3a [C3a(des)-Arg] and C5a [C5a(des)-Arg]), PMN elastase, and malondialdehyde (a by-product of membrane peroxidation by oxygen radicals) were measured daily in 26 septic patients and correlated with two objectively assessed and previously validated severity scores (acute physiology and chronic health evaluation [APACHE II] and Sepsis Severity Score [SSS]). Nonsurvivors (n = 12) had significantly greater and longer lasting complement activation than that in survivors, as reflected by higher levels of catabolic peptides (C3a(des)-Arg) and lower levels of native proteins (C3 and C4). C3a(des)-Arg, C3, C4, and the C3a(des)-Arg-C3 ratio were correlated with Sepsis Severity Scores. Polymorphonuclear neutrophil leukocyte elastase levels were higher in nonsurvivors and were correlated with C3a(des)-Arg and the C3a(des)-Arg-C3 ratio. Malondialdehyde levels were significantly higher in all patients than in controls, without, however, any relationship to severity of disease or clinical outcome. Since the higher and more persistent the complement activation and polymorphonuclear neutrophil leukocyte stimulation, the worse the patient's prognosis, we conclude that these mechanisms may be important in the clinical development of sepsis.


Pancreatic complications following cardiopulmonary bypass. Factors influencing mortality. Pancreatic complications following cardiopulmonary bypass are infrequent but are associated with high mortality. All cases of pancreatic complications following cardiopulmonary bypass from 1972 to 1987 at a single institution were retrospectively reviewed. Of 5621 patients who underwent cardiopulmonary bypass, 25 (0.44%) sustained pancreatic complications. There were 15 cases of acute pancreatitis and 10 cases of pancreatic necrosis, with 11 deaths in the group reviewed, a mortality rate of 44%. Factors that were correlated with mortality associated with pancreatic complications in this study include preoperative hypotension, preoperative use of inotropic agents, and renal failure (preoperative and postoperative). Factors that have been previously associated with mortality from pancreatic complications in other studies, such as fluid sequestration, respiratory failure, sepsis, tachycardia, hypocalcemia, age greater than 55 years, and abnormal laboratory findings, were not found to be significantly associated with mortality in this study. Of the five patients for whom complete data were available, not one patient received greater than 800 mg of calcium per square meter of body surface area in the perioperative period. While the exact mechanism of pancreatic injury remains unclear, based on experimental studies and clinical correlation, it is likely that pancreatic ischemia remains a significant contributing factor. We conclude that no factor specifically associated with cardiopulmonary bypass was correlated significantly with mortality.


A randomized clinical trial comparing two methods of fascia closure following midline laparotomy. Three hundred forty women undergoing midline laparotomy were randomized into an interrupted suture (polyglactin 910, size 1) or a continuous suture (polyglyconate, size 0) closure group. The two groups were well balanced with respect to various risk factors for postoperative wound complications. Early evaluation revealed no differences between the continuous and interrupted suture groups with respect to wound infection (3% vs 1%), superficial wound dehiscence (2% vs 4%), and deep wound dehiscence (0.6% vs 0%). Late evaluation showed no differences between the two groups either. Continuous polyglyconate and interrupted polyglactin 910 sutures had a similar incidence of suture fistula (0% vs 2%), wound pain (1% vs 2%), and incisional hernia (3% vs 4%). Continuous closure was done faster and resulted in less foreign-body suture material. Despite its smaller diameter, the polyglyconate suture also retains a higher tensile strength after surgery than does the quicker-degrading polyglactin 910 suture. Results of this study lead to the conclusion that a running polyglyconate suture is the better choice for closure of the abdominal-wall fascia following midline laparotomy.


Racial differences in the anatomical distribution of colon cancer. The objective of this study was to determine whether racial differences exist with regard to the anatomical distribution of adenocarcinoma of the colon. We conducted a retrospective study of consecutive patients with primary colon cancer seen during a 12-year period (1976 to 1987) identified by the Rush Tumor Registry. The setting was a large, tertiary-care, private medical center, located in the inner city of Chicago, Ill. A chi 2 unpaired Student's t test of association was performed to detect any statistically significant difference in the anatomical sites of distribution between blacks and whites. A statistically significant percentage of black patients had proximally located primary colon lesions compared with white patients. This observation was independent of the actual anatomical definition of right-sided or proximal colon lesions. These findings suggest that a significant percentage of black and white patients are less likely to be diagnosed with colon cancer at a more curable stage, when abiding by the current screening guidelines of the American Cancer Society and the National Cancer Institute. The impact is greater on black patients with adenocarcinoma of the colon.


Repair of parastomal hernias using polypropylene mesh. Parastomal hernias are a common complication of ostomy construction. We have developed a method of repair that uses two strips of polypropylene prosthetic mesh through a midline incision. The medical records of 19 patients who underwent parastomal hernia repair were retrospectively reviewed. All nine patients operated on for this condition by the senior author (R.G.P.) (group 1) underwent repairs with this technique. All ten patients operated on by other surgeons in our center (group 2) underwent repairs in which the stoma was moved, the fascia was directly repaired through a parastomal incision, or the fascia was repaired via a midline incision. No patients in group 1 had recurrences while five patients in group 2 had recurrences. Neither group developed strictures or stomal prolapse. Our method of repair is technically easy and has excellent results. It is especially suitable in very large hernias in which incisional hernia is likely in the original stoma site if the stoma is moved.


Ischemic stricture and perforation. An unusual complication after successful barium reduction of an intussusception. Intussusception is a common cause of intestinal obstruction in infants. Use of a barium enema affords both diagnostic confirmation and a chance for nonsurgical reduction of the intussusception. While failed hydrostatic reduction is an indication for surgical intervention, delayed complications of hydrostatic reduction have not been described. We present a case of ischemic stricture and perforation developing after the successful reduction of an intussusception.


Tubular adenoma of the main pancreatic duct. We report a case of tubular adenoma of the duct of Wirsung with focal villous changes. To our knowledge, this is the 13th reported case of this uncommon neoplasm and the first with a primarily tubular histologic pattern. The patient presented with abdominal pain and diarrhea and was found on endoscopic retrograde cholangiopancreaticography to have a mass in the head of the pancreas, which was confirmed by endoscopic ultrasound. Clinical and pathological features of the 12 previously reported cases are reviewed. Intraoperative testing failed to rule out adenocarcinoma which, in addition to difficulties presented by local anatomic relationships of the tumor, supports wide surgical resection as the preferred surgical solution.