Enterohepatic circulation in hamsters with an extracorporeal bile duct. The present study describes a novel technique for investigations of the enterohepatic circulation in the hamster with an extracorporeal bile duct that allows long-term bile collection in the free-moving animal. The animals recovered for 7 days after the operation before the external loop was cut and bile was collected over a period of 78 h. Under these optimal conditions, initial bile flow (651 +/- 89 microliters per 100 g.h-1) and the secretion rates of biliary lipids were several-fold higher than reported in an earlier study using the acute fistula hamster. Biliary cholesterol secretion amounted to 369 +/- 32 nmol per 100 g.h-1, phospholipid secretion was 2.6 +/- 0.3 mumol per 100 g.h-1, and total bile acid secretion was 31.9 +/- 2.2 mumol per 100 g.h-1. A clearcut diurnal rhythm was demonstrated for bile flow and all biliary constituents. After 9 h the depletion of the bile acid pool was complete and cholic acid synthesis derepressed 1.4-fold from a basal rate of 818 nmol per 100 g.h-1, whereas the derepression of chenodeoxycholic acid synthesis was even less pronounced. Biliary cholesterol output increased 2.2-fold, but the phospholipid secretion was constant during the full experiment. It may be concluded that the technique of an extracorporeal bile duct in the free-moving animal allows studies of bile secretion under optimal conditions. Most likely the bile secretion rates given above approach the physiological rates in the hamster.


Determination of free and amidated bile acids by high-performance liquid chromatography with evaporative light-scattering mass detection. A simple reverse phase high-performance liquid chromatographic method for a simultaneous analysis of free, glycine- and taurine-amidated bile acids is described. The resolution of ursodeoxycholic, cholic, chenodeocycholic, deoxycholic, and lithocholic acids, either free or amidated with glycine and taurine, is achieved using a C-18 octadecylsilane column (30 cm length, 4 micron particle size) with a gradient elution of aqueous methanol (65----75%) containing 15 mM ammonium acetate, pH 5.40, at 37 degrees C. The separated bile acids are detected with a new evaporative light-scattering mass detector and by absorbance at 200 nm. A complete resolution of the 16 bile acids, including the internal standard nor-deoxycholic acid, is obtained within 55 min. Using the light-scattering mass detector, amidated bile acids and, for the first time, free bile acids can be detected with similar detection limits in the order of 2-7 nmol. The new detector improves the baseline and the signal-to-noise ratio over the UV detection as it is not affected by impurities present in the samples with higher molar absorptivity than bile acids or by the change in the mobile phase composition during the gradient. The method fulfills all the standard requirements of precision and accuracy and the linearity of the mass detector is over 5 decade the detection limit. The new method has been used for the direct analysis of bile acid in stools and bile with only a preliminary clean-up procedure using a C-18 reverse phase extraction.


Capillary gas-liquid chromatographic separation of bile alcohols. Gas-liquid chromatographic separation of C23, C24, C25, C26, and C27 bile alcohols with either 3 alpha, 7 alpha-dihydroxylated or 3 alpha, 7 alpha, 12 alpha-trihydroxylated ring system on two capillary columns, CP-Sil-19 CB and CP-Sil-5 CB, is described. Bile alcohols with two ring hydroxyl groups at 3 alpha- and 7 alpha-positions consistently showed larger retention times on CP-Sil-19 CB columns and smaller retention times on CP-Sil-5 CB columns than the corresponding bile alcohols with three ring hydroxyl groups at 3 alpha-, 7 alpha-, and 12 alpha-positions. Resolutions of all bile alcohols were better on CP-Sil-19 CB columns; however, we hope that the gas-liquid chromatographic characteristics on the two columns will be useful for better identification of bile alcohols in biological fluids.


The efficacy of chiropractic manipulation for back pain: blinded review of relevant randomized clinical trials. To assess the efficacy of chiropractic for patients with back pain. Randomized clinical trials (RCTs) on spinal manipulation were identified with a Medline search (1966-1990), by citration tracking, and by manual examination of the relevant chiropractic reference systems [Chiropractic Research Archives Collection and Index to Chiropractic Literature]. [Indexing terms, Medline; backache, musculoskeletal diseases, manipulation, osteopathy or chiropractic in combination with evaluation studies, outcome and process assessment, prospective studies, comparative studies, clinical trials or double blind method. Indexing terms, Chiropractic Research Archives Collection: backache therapy-chiropractic clinical trials, cost benefit analysis, evaluation studies--chiropractic, manipulation--spinal, prospective studies, sciatica-therapy. Indexing terms, Index to Chiropractic Literature, backache therapy, clinical trials, cost benefit analysis, intervertebral disc displacement-therapy.] All RCTs involving chiropractors as therapists. To find additional evidence from nonchiropractic RCTs, chiropractic standards similar to the type of treatment used in nonchiropractic trials were determined by a panel of blinded chiropractors. Review by two blinded reviewers independently, using a list of methodological criteria, each of which was attached to a weight. The maximum was set at 100 points. We identified five chiropractic RCTs. No similarity to chiropractic standards could be detected in any of the nonchiropractic RCTs. No chiropractic RCT had a methodological score of more than 50 points. The authors of four of the trials report favorable results for chiropractic, while one refrains from drawing conclusions. The results of the chiropractic RCTs differed on the timing of maximal effect as well as on the subgroups showing the best treatment results. Although the small number of chiropractic RCTs and the poor general methodological quality precludes the drawing of strong conclusions, chiropractic seems to be an effective treatment of back pain. However, more studies with a better research methodology are clearly still needed.


The effect of manipulation on pain and range of motion in the cervical spine: a pilot study. The objective of this pilot study was to determine the number of patients required for a randomized controlled trial of spinal manipulation for neck pain and to determine if there is a relationship between pain and range of motion (ROM) in the cervical spine. Fifty consecutive outpatients were studied in a pretest-posttest design without long-term follow-up. The patients were taken from a primary cae outpatient teaching clinic specializing in back pain. All patients had unilateral neck pain without neurological deficit. The patients were selected as a consecutive sample. All the patients received a single cervical manipulation. Prior to and immediately after the treatment, cervical ROM was recorded on a goniometer, and pain intensity was rated on the 101-point numerical rating scale. The results show an increase in all planes of post-treatment ROM and a decrease in post-treatment pain scores. Partial correlations between post-treatment ROM and 101-point numerical rating scale scores reveal a significant relationship between a decrease in pain and an increase in cervical rotation (p < .005). Since the results of this pilot study are not controlled, they cannot be seen as proof supporting the clinical efficacy of manipulation for neck pain. However, the correlation between an increase in cervical rotation and a decrease in pain is clinically instructive. In addition, the outcome measures used in this study could prove to be useful in the design of future randomized controlled trials of cervical manipulation.


Three-dimensional head kinematics and clinical outcome of patients with neck injury treated with spinal manipulative therapy: a pilot study. Finite helical axis parameters (FHAP) of the cervical spine and clinical measures were obtained to evaluate neck function and the clinical effects of spinal manipulative therapy in patients with "whiplash" (WL) type neck injury. Descriptive case series, 1 yr follow-up. Three private chiropractic practices. Ten consecutive new patients with a history of neck injury, nine asymptomatic, volunteer controls. A 6-wk regimen of short lever manually assisted adjustments with an Activator Instrument, while acute, four patients received interferential electrotherapy. Cervical FHAP during normal movements, neck pain (visual analogue scale), active cervical range of motion and follow-up questionnaire. Based on six patients, the FHAPs appeared to mirror the clinical condition, being markedly deviant from the patterns observed in the control group for at least one or more of the tracking tasks for all but one of the patients. Mean pain scores decreased from 44.1 to 10.5 (t = 4.93; p < .0001) and mean total range of motion increased from 234 to 297 degrees (t = 5.68; p < .0001). At 1 yr, seven respondents noted stability of their symptoms at or near the level reported immediately after the 6-wk treatment period. Based on these preliminary data: a) FHAPs may aid in diagnosing and monitoring treatment of neck dysfunction, b) spinal manipulative therapy may be beneficial to some patients with neck injury and future study is warranted as a means to promote recovery of patients with neck injuries.


The descriptive profile of low back pain patients of field practicing chiropractors contrasted with those treated in the clinics of west coast chiropractic colleges. To compare the demographic and clinical characteristics of low back pain patients from chiropractic college clinics and private practice settings on the west coast of the United States. A survey analysis of consecutive new patients in a specified time frame from multiple private office settings contrasted with a previous survey of consecutive new patients in a similar time frame from chiropractic college clinics. In the private practice setting, new patients were selected on a consecutive basis as subjects for the study. Selection was limited to low back pain patients. None. This was a self-report survey only. There is a strong similarity of the two low back pain patient groups, with the exception of higher levels of income, work time loss, severity and functional disability reported in the private practice setting. Similarities between the two low back pain patient groups were found in the distribution of gender, age, job description and education. Statistical significances were not determined due to variations in data collection. The two patient populations are reasonably comparable in sociodemographic variables, but clinical variation does exist. These results suggest the need to consider clinical findings when extrapolating research findings in a college clinic setting to the chiropractic profession in general.


The reliability of lumbar motion palpation. This review surveys the literature regarding reliability studies of lumbar motion palpation. Using the indexing terms motion palpation lumbar spine and palpation, the following English language databases were surveyed: a) Medline, including back file; b) Embase; c) Cinahl; and d) Epic. Additionally, a manual search of the Chiropractic Research Archives Collection and JMPT was performed and researchers at Western States Chiropractic College were consulted. Pertinent references cited in bibliographies of retrieved papers were included if contributory. Studies pertaining to intra- and interexaminer reliability of lumbar motion palpation were reviewed. Statistical analysis, subject selection, method of palpation and sources of error are discussed. Multiple variations were noted in type of palpation, subjects examined, statistical analysis and experience of examiners. To date, most studies have demonstrated marginal to poor interexaminer reliability, while good to moderate intrarater reliability has generally been reported.


Metastatic testicular seminoma of the cervicothoracic spine. A case of metastatic testicular seminoma affecting the cervico-thoracic spine is reported along with its clinical and radiographic findings. Case progression is discussed.


Religion, theology, church, and bioethics. Modern medical ethics developed in America after mid-century chiefly at theological schools, but discourse on bioethics soon moved to the pluralist-secular settings of the academy and the clinic, where it acquired a philosophical and intentionally non-religious cast. An effort was made, on the grounds of 'liberal culture' and 'late Enlightenment rationality' to find a framework for inquiry which aspired to the universal. Today, while that language persists, it coexists with, challenges, and is challenged by forms of ethical analysis and advocacy which take into consideration the 'thickness' of complicating narrative and reasoning based in the many religious traditions. It has become incumbent upon advocates of those traditions to propose 'publicly accessible' argument.


Humility in health care.

Humility in health care. Humility, properly understood as a sense of one's limits, is one of the goods internal to the practice of health care. Humility in Christian tradition has both a relational aspect and an epistemological aspect. Each of these is evident in the practice of medicine. In its relational aspect, humility includes reverence or awe for the grace and strength of patients and their care-givers, a sense that the care-provider is not self-sufficient but needs the care-receiver, and recognition of the worth of those who are oppressed and outcast. In its epistemological aspect, humility is exhibited in respect for the meaning system of the patient and recognition of the limits of medical paradigms and their need for correction from the patient's perspective. The power wielded by the profession of medicine in contemporary society does not preclude the exercise of humility within the profession.


Jewish theology and bioethics.

Jewish theology and bioethics. This article explores the theological foundations of both classical and contemporary Jewish ethics, with special reference to biomedical issues. Traditional views concerning God's revelation to Israel are shown to underlie the methodological orientation of classical Jewish ethics, which is both legalistic and particularistic. Contemporary Jewish ethicists, by contrast, have tended to embrace more liberal views of revelation which have mitigated both the legalism and the particularism of their approach. Apart from methodological considerations, much of the content of Jewish medical ethics has also been shaped by theological concerns. Specifically, a Jewish theology of creation provides basic norms and values which inform Jewish responses to a range of contemporary biomedical issues. Finally, it is suggested that the theological roots of this ethical tradition do not disqualify it from making a significant contribution to the wider discussion of biomedical issues in our secular, pluralistic society.


Catholic 'natural law' and reproductive ethics. Catholic natural law has had a long and evolving interest in bioethics. Thomas Aquinas left natural law a legacy of great flexibility in evaluating goods within a whole life. He also bequeathed to the Church the basis for an abolutism on sexual issues. Modern reproductive medicine and a deeper understanding of human freedom have reopened these issues. The Vatican has developed new, holistic arguments to proscribe reproductive interventions, but critics remain unconvinced that marital relationships and goods have been adequately evaluated. The resolution of this debate will require further experience and reflection.


Policy arguments in a public church: Catholic social ethics and bioethics. This paper is an analysis of the relationship of social ethics and bioethics in Roman Catholic theology. The argument of the paper is that the character of both Catholic moral theology and ecclesiology shape the broadly defined interest of the church in bioethics. The paper examines the common elements of social ethics and bioethics in Catholic teaching, describes how ecclesiology shapes Catholic public policy and uses the examples of abortion and health care to illustrate the relationship of Catholic social thought and bioethics. In developing the relationship of these two dimensions of Catholic moral argument the article highlights how the appeal to natural law categories differs in social ethics and bioethics and how the two topics are received differently in the theological community. It also seeks to illustrate how the premises of Catholic social ethics remain central to public positions taken on bioethics.


A computer-based, automated, telephonic system to monitor patient progress in the home setting. In this report we describe an automated, telephonic system to monitor the progress of patients convalescing at home. The system includes a computerized central station that is capable of automated voice communication over the telephone, using voice reproduction, and touch-tone recognition. Peripheral hardware in multiple monitored homes need include only a touch-tone telephone, but may also be augmented by inexpensive, rudimentary diagnostic aids, such as a scale for body weight, a thermometer, or a blood pressure cuff and manometer. Current central hardware includes a NeXT computer, a fax modem, and a specialized telecommunications modem developed specifically for voice telecommunication using the NeXT. The central station acts like a robotic nurse in that it asks patients a series of questions and records the responses. The subjective questions to be asked are patient individualized and pre-selected by the physician from a question menu including items targeted specifically for the patient's disease or condition. In addition, clinical data such as body weight, blood pressure, and body temperature obtained from in-home diagnostic aids may be transmitted to the central station over the telephone using touch tones. The time-of-day and frequency of calling are pre-selectable, according to the patient's preference and clinical status. Data obtained by the central station can be easily accessed by the duty nurse via menu driven software. Reports depicting significant responses as a function of time are generated in graphical format to facilitate rapid identification of adverse trends. Hard copy reports can be dispersed directly by fax. Results from a pilot study show patients with cardiac disease readily use the system without difficulty or complaints. In one patient a five pound increase in body weight was detected, which prompted the patient's cardiologist to adjust his medication. In this way automated telephone follow-up can provide early detection of complications before they become severe, making the home environment safer and more secure for convalescence and contributing to reduced health-care costs.


Data management of an inflammatory bowel disease registry. The history and etiology of inflammatory bowel disease which is characterized by two major disease processes: ulcerative colitis and Crohn's disease, remain unknown. Research is focussing on seven major areas of genetic, environmental and physiologic factors that apparently relate to this disease. Based on this background, a population based Inflammatory Bowel Disease Registry was established in 1987 in the Lehigh Valley area of southeastern Pennsylvania. Consent forms, patient data forms and protocols for operation and implementation were developed, and databases were designed to accommodate demographic, basic history, follow-up and relative history data. The databases were correlated with an IBD registry ID number which both enabled relational analyses and ensured confidentiality of data information. The registry continues to grow, providing feedback for both continued medical research and supportive information for IBD patients and their physicians.


The Iowa Medical Information Network: a concept. Iowa Methodist Medical Center (IMMC) was one of the nation's early developers of a "hospital/physician" system, entering the arena during October 1985, under the direction of Ginny Wagner. Their "MOLI-Link" system now serves over 150 physicians in 50 locations, and is currently undergoing significant enhancement. MOLI-Link was originally developed using Annson Systems (IBAX) products, and has recently migrated to Wallace Computer Services (Wal-Link) software. Over the past 4 years, IMMC has investigated wide-area medical information networking, and is now actively investigating development of the Iowa Medical Information Network. It is envisioned that IMIN would provide clinical, administrative, and educational information services throughout the IMMC 37 county referral area.


CompreLink--a physician to physician communication network. The Cleveland Clinic Foundation has developed a physician to physician communication network designed to meet the needs of their affiliate physicians--physicians who do not have admitting privileges at the Cleveland Clinic Hospital. This paper provides an overview of the CompreLink network as it exists today, as well as a glimpse into some of their plans for network expansion and development.


Synapse Health Resources Online.

Synapse Health Resources Online. The University of Nebraska Medical Center maintains the Synapse Health Information Network to provide timely clinical and library resource information to health professionals across Nebraska and surrounding regions. The system is in over 115 sites across Nebraska and surrounding regions and maintains over 320 network users.


US HealthLink: a national information resource for health care professionals. US HealthLink is a new, comprehensive online medical information system designed specifically for health care professionals. Available to individuals for a fixed fee, it includes literature, news, diagnostic decision support, drug interactions, electronic mail, and bulletin boards. It also provides user-specific current awareness via clipping service, and fax delivery of both clipping and electronic mail information. US HealthLink can now be utilized to access a wide variety of medical information sources inexpensively.


Two hundred and fifty patients with hemifacial spasm treated with botulinum toxin injection. Two hundred and fifty patients with hemifacial spasm from the Movement Disorder Clinic, at Siriraj Hospital have been treated with botulinum toxin injection since January 1989 as a collaborating research project with Smith-Kettlewell Eye Research Institute in San Francisco. Each patient received 30 units in four injection sites over the hyperkinetic facial muscles. There were 169 female and 81 male patients, the sex ratio of female to male was 2.1:1. The mean age of all patients was 50.2 +/- 12.6 years with the range of 22 to 78 years. The majority of patients had been suffering for 3-10 years. The results of botulinum toxin injection were classified as excellent in 81.2 per cent, moderate improvement 10.0 per cent, mild improvement 6.8 per cent and no improvement or worse in 2.0 per cent. There were complications of mild transient facial weakness in 44 patients (17.6%) mild ptosis in 7 patients (2.8%) and excessive lacrimation in 1 patient (0.4%). The effect of botulinum toxin treatment lasted for 3-6 months duration. Botulinum toxin injection is a simple and effective out-patient treatment for patients with hemifacial spasm with no systemic side effects and minor transient local complications.


Spontaneous pneumothorax in chronic obstructive pulmonary disease. There were 34 episodes of pneumothorax out of 400 episodes of COPD (i.e. 8.5% of the total) among patients who were admitted to Chulalongkorn Hospital during the period 1982 to 1986; the episodes of pneumothorax occurred among 22 males and one female, with the average age on admission being 64.0 +/- 8.5 years. All patients had a long history of smoking (average 40 years) with a history of recurrent pneumothorax (47.8%) and two episodes of pneumothorax per patient. Since only about one third of our patients had chest pain or positive signs of pneumothorax on physical examination, the possibility of pneumothorax should be considered in every patient who develops sudden and increasing shortness of breath, especially during mechanical ventilation, or even in association with other obvious precipitating factors, e.g. URI. With regard to complications, there were eight, four, two, two and five episodes of severe respiratory failure requiring assisted ventilation, tension pneumothorax, bilateral simultaneous pneumothorax, pneumomediastinum with subcutaneous emphysema, and plural effusion, respectively. The death rate was 23.5 per cent. Patients who had a pneumothorax requiring assisted ventilation or who developed a pneumothorax during assisted ventilation had a grave prognosis because of multiple complications from mechanical ventilation. Two episodes with minimal pneumothoraxes achieved re-expansion after conservative treatment. The treatment required 3.3 days for the lung to fully expand, 9.6 days when the air-leak stopped and the duration of tube drainage was 10.8 days. Our study indicates that the longer the duration of lung collapse the longer the time required for re-expansion of the lung.(ABSTRACT TRUNCATED AT 250 WORDS)


Lipid disorders in Thai diabetic patients at Rajavithi Hospital. Lipid abnormalities are common in diabetic patients. In this study, 71 per cent had hyperlipidemia. The incidence of combined hyperlipidemia, hypertriglyceridemia, and hypercholesterolemia were 29.5, 25.8 and 15.5 per cent respectively. Females were found to have higher cholesterol levels than males. Cholesterol and triglycerides levels were correlated with BMI and GHb but showed no correlation with age and duration of diabetes. HDL-C showed no correlation with BMI, GHb, age or duration of diabetes.


The epidemiology of insulin-dependent diabetes mellitus (IDDM): report from Thailand. The epidemiology of diabetes mellitus in Thai children aged 0-15 years was studied in 1985 and compared with a previous study done in 1984. Four hundred and seventy-six questionnaires were sent each year to hospitals in Thailand. In 1984, thirty-six cases of newly diagnosed diabetes mellitus were found of which 35 were IDDM and one was NIDDM. In 1985, twenty-seven cases of new IDDM were found, no case of NIDDM was reported. Two cases of MRD were reported from the Northeastern and Southern part of Thailand. The incidence of IDDM in the whole kingdom of Thailand was 0.19/100,000/year in 1984 and 0.14/100,000/year in 1985. The male to female ratio was 1:1.5 in 1984 and 1:2 in 1985. The peak age at diagnosis showed the main peak at 14 years old in boys. The peak age of girls preceded boys by 1-2 years in 1984 and 1985. Similar findings in 1984 and 1985 were the onset of symptoms showing a seasonal variation with highest frequency in winter with a slight change of increased incidence in the rainy season of 1985. There was an increased incidence of IDDM in families with lower educational and socioeconomic levels. The newly diagnosed IDDM with DKA was 16.2, and 19.5 per cent in 1984 and 1985. The incidence of IDDM in Thai children, aged 0-15 years seems to be the lowest compared to other countries previously described which might be due to some genetic and environmental including diet, micronutrient, eating habits and life-style which might play a role in the difference.


The failure of a preprinted order form to alter physicians' antimicrobial prescribing pattern. Use of antimicrobial agents is highly effective in reduction of morbidity and mortality due to infectious disease. There is, however, evidence that the use of such agents is frequently inappropriate worldwide. Several methods were tried to rationalize the use, and, among these, the preprinted order form (P.O.F.) offered the simplest and most efficient way. We studied the use of the P.O.F. in Siriraj Hospital, Bangkok Thailand, where there was overuse of antimicrobial agents using a historical-controlled intervention study. In period I (no P.O.F.), the antimicrobial overuse was 35 per cent, and this was not reduced by using the P.O.F. in period II (32%), which was one year apart. There was no difference in overuse after adjustment for differences in base-line characteristics which were thought to affect antimicrobial prescriptions i.e. physicians' workload, physicians' knowledge and the method of diagnosis of infectious disease. Reasons for failure of the P.O.F. in unclear. Misdiagnosis was unlikely since the correct diagnosis as revised by attending physicians and specialists was as high as 83 per cent. The fear of malpractice suits was also not the reason because defensive medicine is not a problem in Thailand. The nature of the diseases, which lower the threshold to treat, the clinical immaturity and other unknown factors were thought to play a part in deviation from responsibility to perform according to written-justification.


Prevalence and intensity of Opisthorchis viverrini in rural community near the Mekong River on the Thai-Laos border in northeast Thailand. The prevalence and intensity of Opisthorchis viverrini in fourteen villages in Nakhon-Phanom province, Northeast, Thailand have been investigated. Overall prevalence of O. viverrini infection was 66.4 per cent in a total population of 2,412 individuals. The prevalence was 18.5 per cent in children under 5 years, 38.9 per cent in those aged 5-9 years, and ranged from 64.9 per cent to 82.2 per cent in the age group above 10 years. The intensity of O. viverrini infection increased with age. The mean faecal egg output was highest in the 30-34 year age group and remained relatively constant through older ages. In all age groups the prevalence and intensity of infection in both men and women were similar. The population was divided according to the presence and intensity of infection as follow, 33 per cent were uninfected, 59 per cent had light infections (less than 1,000 eggs per g of faeces; EPG), 7 per cent had moderate infections (1,000-10,000 EPG), and 1 per cent had heavy (greater than 10,000 EPG). Other important intestinal infections found in this community are hookworm, Taenia spp. and Trichuris trichiura with the prevalence of 17.9 per cent, 1.1 per cent and 1.1 per cent respectively.


Liquid meal emptying in non-ulcer dyspepsia: a study in 22 Thai patients. Twenty-four patients with non-ulcer dyspepsia (NUD) were recruited for gastric emptying study of liquid meal before and after 1 week's treatment with domperidone (80 mg in 19, 40 mg in 2, dropout 1 and excluded 2). Delayed gastric emptying was found in 8 of 22 (36.36%). Clinical improvement was found in 11 patients after treatment. Gastric emptying improvement was found in 3 patients (2 without clinical improvement). No correlation was found between the clinical and gastric emptying improvement. (Fisher exact test p greater than 0.25). Impaired liquid emptying is common in NUD and domperidone improved clinical symptoms in 50 per cent of NUD in this study.


Compartmental change after weight reduction in childhood obesity. Ten obese children aged 8-13 years participated in a 4-week program of weight reduction. Dietary restriction of 800 kcal/day and mild exercise were the two features of the program. With this regimen the investigators expected that their lean body mass would be preserved while body fat would decrease. After the 4-week program, we found that those who were mildly and moderately obese lost more than 5 per cent of their body fat but less than 1 per cent of lean body mass. Those children with morbid obesity lost more than 5 per cent of body fat and lean body mass. It is concluded that the regimen is suitable for mild and moderate obesity, but for morbid obesity, a new regimen with higher energy and higher protein in the diet may be more suitable than the current one.


Human pythiosis in Srinagarind Hospital: one year's experience. We have reported four cases of human pythiosis arteritis from Srinagarind Hospital, Khon Kaen, Thailand. This unusual human infection occurring perhaps exclusively in thalassemia and hemoglobinopathy patients, should be noted by physicians, who work in areas with a high incidence of hemoglobinopathy, and for patients who present with unexplained arterial insufficiency. As our reported cases occurred within only one year, this condition may be more common than originally suspected and found more frequently if actively searched for.


Eales' disease with myelopathy.

Eales' disease with myelopathy. The first Thai case of Eales' disease with myelopathy is reported. This entity must be differentiated from other causes of myelopathy such as those due to infectious-inflammatory causes. The ophthalmologic findings are the most important diagnostic clues. Since many infectious diseases such as tuberculosis and dental sepsis may be potentially related to Eales' disease, and these infections are rather common in Thailand, the diagnosis of Eales' disease with neurological complications especially myelopathy should be looked for.


Problems in surgical treatment of congenital clubfoot. Twenty-three patients with 32 congenital rigid clubfeet treated by posteromedial release were reviewed after a follow-up averaging 33 months. The feet were assessed both clinically and radiologically; a satisfactory result was obtained in 17 feet inspite of residual deformity of forefoot adduction. Early operation and adequate postoperative immobilisation were major factors in contributing to a satisfactory result.


Limb salvage for extremity sarcoma in Ramathibodi Hospital. From May 1986 to July 1991, a retrospective review of 27 patients treated with limb salvage surgery for extremity sarcomas, was evaluated by our team. There were 12 males and 15 females with a mean age of 22.7 years (ranging from, 9 to 53 years). The mean of the follow-up period was 27.6 months. (ranging from 6 to 62 months). Twenty-four patients had bone sarcomas which included 20 osteosarcomas, 3 chondrosarcomas and one adamantinoma. The locations of bone sarcomas were the proximal tibia (6 cases), distal femur (5 cases), proximal humerus (4 cases), proximal fibula (3 cases), scapula (3 cases), proximal femur (1 case), tibial shaft (1 case) and pelvis (1 case). The remaining three patients had malignant fibrous histiocytomas located in scapular, tibialis anterior muscle, and knee regions. In total there were 1 stage IA, 2 stage Ib, 1 stage IIA and 23 stage IIB. Twenty-four cases had wide excisions; two had marginal excisions and one radical excision. There were 17 bone reconstructions consisting of 11 allografts and 6 autografts. At the most recent follow-up examination, 74 per cent of the patients are alive and the overall disease free survival was 63 per cent. Local recurrences occurred in 11 per cent. The major complication rate was 3 per cent and the minor complication rate was 33 per cent. With respect to a functional outcome, 84 per cent of the patients achieved excellent or good results.(ABSTRACT TRUNCATED AT 250 WORDS)


Chondrodysplasia punctata: a case report. Chondrodysplasia Punctata is a rare condition in which there are numerous punctate areas of calcification in the epiphysis. The disease involves not only skeletal but also the cardiovascular, cutaneous, ocular and central nervous system. We present a newborn case with clinical as well as radiographic findings similar to Chondrodysplasia Punctata.


Malignant osteoblastoma versus osteosarcoma: a case report. A 33-year-old male developed a slow-growing mass at the anterior aspect of the left tibia for 8 months. The radiologic finding revealed a well-circumscribed osteolytic mass and appeared benign to most radiologists. The lesion was then excised locally. The histology revealed bizarre osteoblasts and osteoclast-like giant cells interspersing in the vascularized stroma and trabeculated osteoids; the periphery of the lesion showed sclerotic mature bones. Malignant osteoblastoma was, therefore, entertained and the patient was treated as such without aggressive surgery and chemotherapy. He has survived for 11 years. However, the diagnosis of malignant osteoblastoma was still a contradiction because of the presence of cartilage foci.


Metastatic bone tumors in Ramathibodi Hospital, Thailand during 1985-90. The study was aimed to analyse the histologic typings of metastatic bone tumors, age of patients and skeletal distributions in Ramathibodi Hospital. There were 122 cases of metastatic bone tumors out of 217 cases of all malignant bone tumors as retrieved from the files of surgical records in the Department of Pathology, Ramathibodi Hospital from 1985 to 1990. Approximately 80 per cent of metastatic bone tumors were carcinomas of which adenocarcinoma was the most common and accounted for 44.3 per cent of all metastatic bone tumors. The most common site of biopsy which possibly reflects the skeletal distribution of metastases was the vertebra which accounted for 35 per cent. The average age of patients presenting with metastatic carcinomas was about 50 years which was comparable to those of other series. It was obvious that biopsy of metastatic lesions was helpful in narrowing the scope of investigation but could hardly define the primary sites without further investigations.


Paget's disease of bone--clinico-pathology study of the first case report in Thailand. Paget's disease of the bone is rare in Asia. We report a case of Paget's disease with clinico-pathology study and it appears to be the first case in Thailand. The case was a 44-year-old female of Chinese descent who developed pain in the left hip and sacral area for one year prior to admission to Vachira Hospital. The earlier clinical diagnoses were either osteoporosis or metastatic tumor. Biopsy of the right iliac bone was typical for Paget's disease of the bone.


Soft tissue tumors in Ramathibodi Hospital: study of 1,682 cases during 1977-1986. A series of 1,682 cases in the service of the Department of Pathology, Ramathibodi Hospital from 1977 to 1986 was studied and classified according to WHO histologic typing of soft tissue tumors. The findings revealed that the three most common benign soft tissue tumors were lipoma (50.6%), vascular tumors (17.4%) and neurofibroma (7.3%), whereas, the three most common malignant soft tissue tumors were unclassified sarcoma (16.5%), rhabdomyosarcoma (15.5%) and neurofibrosarcoma (10.7%). Lipoma occurred at any age group with a mean age of 40 years and affected males and females equally and common sites of involvement were neck (19.7%), back (19.7%) and upper arm (18.4%). Unclassified sarcoma was the most common among the malignant group accounting for 16.5 per cent of the total malignant soft tissue tumors. The age ranged from 7 to 70 years with a mean age of 27.4 years. The most common sites of involvement were the extremities (50%) especially the thigh.


Urinary vanilmandelic acid determination using column chromatography. A simple method for determination of urinary vanilmandelic acid, VMA, using column chromatography was described. The interfering substances in the urine were eliminated by passing the urine through a Dowex-1 x 2, 50-100 mesh, column and washing the column with distilled water. The VMA was eluted from the resin using K2CO3-containing 3.0 mol/l NaCl solution and determined spectrophotometrically after periodate oxidation reaction. This method yielded a standard curve which was linear up to 50 mg/l. The recoveries of the method as determined by addition technique ranged from 92.1 to 100.4 per cent with an average of 97.3 per cent. The method yielded satisfactory precisions with the coefficients of variation (C.V.) of less than 5.50 and 6.95 per cent for within-run and between-run experiments respectively. The method was sensitive to the concentrations of 1.2 mg/l with recovery of 92.5 per cent and 2.6 mg/l with the recovery of 109.9 per cent for the standard and urinary VMA respectively. No interfering effects were found from epinephrine and norepinephrine (up to 2,000 micrograms/l), acetylsalicylic acid (up to 50 mg/l) and homovanillic acid (up to 10 mg/l) added to the pooled urine. The correlation coefficients (r) of 0.909 (n = 100) and 0.905 (n = 100) were obtained when the urinary VMA values determined by the proposed and Pisano's methods and expressed as mg/l and mg/g creatinine were compared respectively. The column could be reused at least 5 times. The technique is suitable for any routine clinical laboratory.


Morphological variation in pathogenic strains of Penicillium marneffei. Penicillium marneffei is a dimorphic fungus known to be pathogenic to animals and man. The natural reservoir of this organism was known to be bamboo rats found in South Vietnam, Thailand and China. The first two human infections were reported in 1959 and 1973 from the United States. Up to 1984, five new cases of human penicillosis were reported from Thailand. Since then several more cases have been reported from different parts of the world mainly from the southern part of China. However, there are very limited mycological descriptions of this fungi. In this report, five Thai strains were studied for colonial morphology in comparison with Reference strain PLM 689. Variation in mycelial pigment was observed ranging from yellowish-green to orange with water soluble red pigment produced in every strain which can be seen early from the reverse side. Ultrastructural study by both scanning electron microscopy (SEM) and transmission electron microscopy (TEM) was compared with that of the reference strain PLM 689. PLM 689 strain had only biverticillate penicilli, but all five strains from Thailand had both monoverticillate and biverticillate penicilli which occasionally appeared on the same branch. The conidia of the Thai isolates were oval in shape and 1.3-2 x 0.7-1.6 microns in size smaller than those of PLM 689 which were 2.5-4 x 2-3 microns. Phialides were also smaller and a little shorter but the number of phialides was similar to those of PLM 689 ranging 4-10 except for one strain which had 3-16 phialides. All Thai strains have stipes smaller and somewhat longer than those of PLM 689.(ABSTRACT TRUNCATED AT 250 WORDS)


Microscopic examination of Cryptosporidium oocysts in diarrhoeal stools. Unconventional microscopic means for investigation of Cryptosporidium oocysts in patients' stools were explored in an attempt to obtain a more accurate diagnosis. The results showed that Nomarski interference contrast microscope provided clearer structures of oocysts in wet mount preparations than those under a normal light microscope and readily allowed distinction from yeast cells. Transmission electron microscopic study revealed that oocysts are thick walled and well sporulated. Their "untypical" appearance as seen by the light microscope resulted from sporozoites or the residuum that can be unfamiliar to some examiners. Electron microscopy provides definitive identification of Cryptosporidium spp. but Nomarski interference contrast microscopy was superior to bright field microscopy and may facilitate rapid diagnosis in routine fecal examination. The Ziehl-Neelsen modified acid fast technique was of value for differentiation and confirmation.


Evaluation of a locally developed direct immunofluorescence test for chlamydial infections. The high cost of diagnostic tests for chlamydial infections limits their use which may result in under estimation of the incidence of chlamydial infections. This study was an attempt to reduce the cost of the test by developing an immunofluorescence test for C. trachomatis using monoclonal antibody to major outer membrane protein of C. trachomatis. Urethral swabs were obtained from patients with symptoms of urethritis. The developed immunofluorescence test was compared with culture method and a commercial immunofluorescence test kit (BioMerieux). Compared with the culture method, the sensitivity, specificity, predictive value of positive and predictive value of negative of the developed test were 79, 85, 61 and 93 per cent respectively. The results obtained from the comparison with commercial test kit showed an agreement of 88 per cent. The developed test was positive in 32 per cent of specimens while the commercial test was positive in 24 per cent. The commercial test kit showed excellent reactions and it contained monoclonal antibody to lipopolysaccharide of Chlamydiae in addition to monoclonal antibody to major outer membrane protein which can lead to stronger immunofluorescence staining. The locally developed test, however, costs much less without compromising the results.


Hematological and coagulation studies in malaria. One hundred and twenty-six patients with malaria (30 cases of P. vivax and 96 cases of P. falciparum) were studied for evidence of hematological coagulation and fibrinolysis abnormalities. Anemia associated with malaria was observed only in P. falciparum infections and there was no correlation between the degree of anemia and the percentage of parasitemia. Decreased hematocrit levels were found to be statistically significant in P. vivax infected patients (P greater than 0.05). Thrombocytopenia was observed in both P. vivax and P. falciparum malaria patients (P less than 0.001) and correlated with the degree of parasitemia (r = 0.974). Plasmin activity was normal in P. vivax malarial patients but it was significantly increased in patients with a P. falciparum of more than 5 per cent parasitemia. Coagulation profiles showed normal PT, aPTT, and TT in P. vivax infected patients while prolonged PT and aPTT were observed in P. falciparum infection which correlated with the degree of parasitemia (r = 0.0992). Coagulation factors V, VII, and IX were the most sensitive parameters in the expression of coagulation defects and most coagulation abnormalities were due to liver involvement. However, 2 of 20 complicated cases of P. falciparum showed evidence of disseminated intravascular coagulation (DIC).


An unusual adhesion between red-cells and platelets in falciparum malaria. A Thai female patient infected with P. falciparum had 80 per cent P. falciparum infected red cells at ring stage in the peripheral blood smear. The complications included anemia, thrombocytopenia, acute renal failure and pulmonary edema. A marked decrease in platelets number, low hemoglobin, low hematocrit and decreased red blood cell count were detected. More than 70 per cent of total platelets detected in the blood smear were binding to parasitized red blood cells. The number of binding platelets declined with decreasing per cent parasitized red cells. It was also noted that some platelets (10-20%) adhered to nonparasitized red cells. An increased number of large lymphocytes was shown by increased numbers of large unstained cells (LUC) by H* 1 automated analyzer. The peripheral blood smear showed abnormal binding of platelets to the infected red cells more frequently than to non infected red cells and free platelets on the day of high parasitemia. This abnormal phenomena was related to the number of platelets in the circulation. When the parasitized red cells were not detected in the blood smear, the number of platelets in the circulation had returned to normal.


Immunological and immunopathological studies of patients with burn scar. Sera obtained from 5 cases of burn scars (patients group 1) and cases of burn scars with squamous cell carcinoma (patients group 2) of the skin are analysed for anticollagen antibodies. Anticollagen type VI was demonstrable in the serum of one out of 5 cases in group 1 and 4 out of 6 cases in group 2. Collagen type VI was demonstrable in the scar without carcinoma of one patient whose serum contained anticollagen type VI. It is suggested that collagen type VI in the scar and their immunobiologic reaction may be related to the regulation of tumor development in scar tissue of the skin.


Enzyme-linked immunosorbent assay for leptospirosis immunoglobulin M specific antibody using surface antigen from a pathogenic Leptospira: a comparison with indirect hemagglutination and microagglutination tests. A search for a sensitive and specific test for human leptospirosis was made by enzyme-linked immunosorbent assay for immunoglobulin M specific antibody (IgM ELISA) using a surface antigen from L.interrogans serovar bataviae, L. interrogans serovar pyrogenes and L.interogans serovar icterohaemorrhagiae. The IgM ELISA tests using each of the three antigens were evaluated in 103 sera primarily positive by microagglutination test (MA). Optical density of these IgM ELISA tests showed good correlation. The IgM ELISA using antigen from serovar bataviae was compared with MA and indirect hemagglutination (IHA) in 20 sera primarily positive by IHA, and 103 sera primarily positive by MA. IgM ELISA and IHA using antigen prepared from serovar bataviae in 103 sera positive for MA had a sensitivity of 98.06 and 92.23 per cent respectively. In 20 sera primarily positive by IHA, IgM ELISA and MA showed sensitivity of 80 and 45 per cent respectively. The surface antigen used in IgM ELISA is broadly specific making IgM ELISA a sensitive and specific test for human leptospirosis. IHA agreed more with IgM ELISA in comparison to MA. As MA is not sensitive for early infection, IHA and IgM ELISA should be in routine use in general laboratories.


Clinical features of acute lymphoblastic leukemia subclasses in 28 Thai children--a preliminary study. Twenty-eight Thai children with newly diagnosed acute lymphoblastic leukemia were evaluated for pretreatment characteristic, including immunophenotype of lymphoblast, outcome of treatment, and the correlation among them. By APAAP technique using a panel of eight monoclonal antibodies (HLA-DR, CD 19, CALLA (CD 10), IgM, CD 7, CD 3, CD 4, and CD 8), five subclasses were identified: 67.9, 17.9, 7.1, 3.6, and 3.6 per cent were respectively shown to be common-, null-, mature thymocyte T-, pre B-, and B-ALLs. Clinical features in each subclass conformed to previous reports. All of the 27 evaluable patients attained initial complete remission, but subsequent relapses were noted in 7 patients (25.9%). Three of the 19 cases in the common ALL group relapsed at 6-12 months, whereas, 4 of the 8 cases in the non-common ALL group relapsed at 2-15 months. Probability of relapse at 12 months in the common and non-common ALL groups were 19 and 49 per cent respectively. Disease-free survival from time of remission was shorter in the non-common ALL group. Multivariate analysis of the 6 factors predicting disease-free survival showed that the only strong factor was the immunophenotype of lymphoblast.


Immunophenotype and cytochemical reactions of acute lymphoblastic leukemia in Thai children. The immunophenotypes of acute lymphoblastic leukemia (ALL) in 28 Thai children were studied by the APAAP technique using a panel of eight specific monoclonal antibodies: HLA-DR, CD 19, CALLA (CD 10), IgM, CD 7, CD 3, CD 4, and CD 8. Sixty-eight, 18, 3.5, 3.5, and 7 per cent were respectively shown to be common, null, pre-B, B, and mature thymocyte T subtypes. Cytochemical reactions (beta-glucuronidase, alpha naphthyl acetate esterase, and acid phosphatase) in this study could identify null, common, and T ALLs with confidence, and could be used in the process of ALL subtyping to reduce cost.


Thalassemic red cells determined by different technology of blood cell analysers. Blood samples from 12 normal cases and 30 thalassemic patients were analyzed by four blood cell analysers (the H*1, Baker 9,000RX, Coulter JT, and Argos). These four machines had different technology: light scattering using laser beam (H*1) and electronic aperture impedance (Baker 9,000RX, Coulter JT, and Argos). Analysis of normal blood samples showed comparable red cell parameters between these four machines except the value of RDW. When the thalassemic blood samples were determined using these four types of blood cell counters, many red cell parameters showed significant difference. This indicates that thalassemic red cells which are known as the abnormal cells in terms of their volume, shape, intracellular hemoglobin content, and osmotic fragility, responded differently to the reagents and technology of blood cell analysis. Calibration of the instrument using qualitatively abnormal blood sample, is recommended.


Different cell volume with high target cell population between liver disease and homozygous hemoglobin E. Blood samples with increased percentage of target cells were collected from liver disease, thalassemia, homozygous hemoglobin E (E/E), and nonidentified cases. Normal cases who had no history of liver disease and normal hemoglobin typing were also included in the study for control. Patients with liver disease had increased target cell percentage with normal MCV, whereas, the other three groups had increased target cell percentage and reduced MCV. The difference was more obvious when compared with liver disease and homozygous Hb E cases. These two groups had comparable target cell percentage (14.36 +/- 4.77 in liver disease, and 14.22 +/- 1.59 in homozygous Hb E) and comparable degree of anemia (Hb level in liver disease = 11.19 +/- 0.39, and 11.30 +/- 0.16 in homozygous Hb E) but they showed a statistical significance (p less than 0.0001) between MCV (79.66 +/- 2.18 fL in liver disease, and 60.40 +/- 0.75 fL in homozygous Hb E).


Cytochemical reactions of homozygous beta-thalassemic spleens. Splenic cells from 10 homozygous beta-thalassemic patients were stained using cytochemical reactions: non specific esterase and acid phosphatase. Spleens from nonthalassemic subjects: a normal case who underwent gastric surgery and 5 idiopathic thrombocytopenic purpura, were also studied to serve as the control. In thalassemic spleens, no positive dot cell was shown in periarteriolar lymphocyte sheaths (PALS) when they were stained with both nonspecific esterase and acid phosphatase. In contrast, dot positive reaction was demonstrated in 92 per cent of cells from a normal spleen. These cells were presumably T lymphocytes. There were two possibilities to explain our study 1) the absence of T lymphocytes in the PALS of white pulps in homozygous thalassemia may have an impact on the immune system related to infection complication in thalassemia 2) T lymphocytes in the thalassemic spleen may be present but they do not give a positive ANAE dot reaction.


Cytometric analysis of paroxysmal nocturnal hemoglobinuria erythrocytes. Erythrocytes from six cases of paroxysmal nocturnal hemoglobinuria (PNH) were analysed by the H*1 hematology analyser using laser inspection for each individual red cell. The computer program categorized the red cells into 9 groups based on the data of red cell volume and intracellular hemoglobin concentration. The only 46.3 +/- 10.9 per cent (Mean +/- SD) of PNH red cells were normochromic normocytic. Hypochromia (hemoglobin concentration less than 28 g/dL) with normal red cell volume (between 60 to 120 fL) were found in 22.8 +/- 19.7 per cent and with large cell volume (greater than 120 fL) = 14.9 +/- 4.5 per cent of total red cells. Large cells with normal hemoglobin concentration were found in 12.9 +/- 13.2 per cent. The red cells had increased heterogeneity in red cell volume measured as red cell distribution width (RDW), Mean +/- SD = 23.6 +/- 2.3 per cent and increased heterogeneity in their hemoglobin concentration distribution with (HDW) (3.4 +/- 0.5 g/dL). The high RDW was resulted from increased number of varying size of macrocytes and the high HDW was caused by the increased number of hypochromic red cells. Heterogeneity in PNH red cell population described in this study has been postulated to relate with the clonal abnormality of the PNH red cells.


Fetal red cell staining: method evaluation. Acid elution methods have been extensively used for the identification of fetal red cells in pregnant women with fetomaternal hemorrhage. A number of methods have been described: Kleihauer-Betke, Boehringer Mannheim, Fetaldex, Nierhaus-Betke modification and Sanguansermsri amido black B. A comparative evaluation of these methods was performed in this study. The technique of Sanguansermsri using amido black B was found to be more advantageous than the others in terms of simplicity, accuracy, precision and time taken.


Measurements of cell volume and hemoglobin concentration of erythrocytes from hereditary ovalocytosis and hereditary spherocytosis. Red cell analysis using the laser technique was done on erythrocytes from 11 cases of hereditary ovalocytosis (HV) and one case of hereditary spherocytosis (HS). Heterogeneity in red cell volume measured as red cell distribution width (RDW) and heterogeneity of hemoglobin concentration in the red cells as measured by hemoglobin concentration distribution width (HDW) were analyzed. All of the studied cases showed abnormal increase in both RDW and HDW. The patient with HS had decreased MCV 77.4 fL (normal range = 80-99 fL). The HS patient had microcytes 14.7 per cent with markedly increased RDW 22.3 per cent (normal range = 11.5-14.5%). Increased hemoglobin concentration was demonstrated in HS red cells as shown by increased CHCM 39.2 g/dl (normal range = 33-37) with 5.86 g/dl of HDW (normal range = 2.2-3.3 g/dl). The HV patients had slightly decreased cell volume, MCV = 84.1 +/- 11.8 fL, with 9.2 +/- 10.1 per cent microcytes and 17.5 +/- 5.7 per cent RDW. Decreased hemoglobin concentration was shown in HV red cells as shown by decreased CHCM (31.7 +/- 1.9 g/dl) with slightly increased HDW (3.3 +/- 0.9 g/dl). The HV patients had increased per cent hypochromic red cells (14.8 +/- 18.6%). The ovalocytic red cells in HV patients had obviously reduced hemoglobin concentration compared to the spherical red cells of HS patients.


Heterogeneity of antibody response to glomerular basement membrane antigen in patients with different forms of glomerulonephritis. Antibodies to collagenous and noncollagenous components of glomerular basement membrane (GBM) have been detected by immunoblotting in some sera from patients with various kinds of glomerulonephritis. A half proportion of patients with rapidly progressive glomerulonephritis (RPGN), chronic focal glomerulonephritis (CFGN), idiopathic membranous glomerulonephritis (MGN). IgA nephropathy and lupus nephritis (LE-GN) had IgG antibodies to heterogenous components in acid insoluble fraction of pepsin digested GBM. This acid insoluble fraction represented a complex of collagen and noncollagenous proteins of GBM. Following digestion of acid insoluble fraction with bacterial collagenase, the triple helical collagenous components of GBM were destroyed and released most likely of noncollagenous proteins. Antibodies to this noncollagenous proteins were found in only some patients with chronic glomerulonephritis (17.6%) and lupus nephritis (21.4%). Upon reaction with human placenta derived type IV collagen, different frequencies of antibody response were found in patients of different groups. However, all these reactive sera showed a similar immunoblotting pattern. The relationship between antibody response to antigenic components from human GBM or human placenta and pathogenesis of renal disease is unclear. However, the occurrence of spontaneous autoantibody response to some exposed GBM self antigens may mediate further renal destruction resulting in chronic ongoing stage of the disease.


Effect of vegetable oil intake on erythrocyte physical properties and hemorheology. Effects of vegetable oil intake on red cell physical properties and blood flow condition were evaluated. The study was done on two groups of volunteers taking either soybean oil (6 volunteers) or palm oil (another 6 subjects) for a period of eight weeks. The continuous effects were followed up after continuing the vegetable oil intake for another four weeks. Significant reduction in red cell deformability was demonstrated by laser diffractometry in both groups. The palm oil had greater extent in causing reduced red cell deformability as early as four weeks after the oil intake, whereas, such effect was shown in eight weeks after the soybean oil intake. The reducing effect of red cell deformability by palm oil intake was more obvious than that by the soybean oil intake as indicated by the fall of deformability index from the control by 47.6 per cent in palm oil and 21.9 per cent in the soybean oil group. The decrease still persisted and could be investigated on the four weeks' followup. The hematologic parameters measured by the laser-based instrument, the H*1 analyser were all within the normal ranges in both groups. However, the group taking soybean oil showed decreasing hemoglobin levels, which may be a physiological response to facilitate blood flow condition. The platelet volume was increased in both groups, indicating the possibility of adjustment of thrombopoiesis in the subjects although no clinical indication related to this finding was shown. In conclusion, intake of vegetable oil had an effect on red cell deformability. Soybean oil had an advantage over palm oil in having less effect on reducing the red cell deformability.


Standardization of platelet aggregation test in normal Thai adults. Platelet aggregation test was assessed by the turbidimetric method in 52 normal Thai adults consisting of 24 males and 28 females with ages ranging from 20 to 50 years. The aggregating agents used were adenosine diphosphate (ADP), adrenaline and collagen. It was found that the ranges of threshold concentration of ADP, adrenaline and collagen which gave maximal induction of platelet aggregation were 5-10 microM, 2.5-10 microM and 0.14-0.28 mg/mL, respectively. Collagen at the above concentration, showed lag phase within 2 minutes. This corresponds to that described in the reference method. Moreover, when induced by ADP and adrenaline 53-65 per cent and 81-87 per cent of the subjects, respectively, showed biphasic curve. The above concentration of ADP, adrenaline and collagen are suitable for the study of platelet aggregation in normal Thai adults.


Endomyocardial biopsy: a review of its current role and usefulness. Endomyocardial biopsy via transvascular technique is safe. It shows a wide range of clinical applications. The fresh endomyocardial tissue thus obtained is very helpful for further research in the field of cardiac pathology. It facilitates almost all sophisticated techniques that need fresh and viable cells. Results of the study are relevant and mostly clinically useful. However, application of this technique to the study of heart diseases in Thai people is still limited. This may be partly due to excessive patient fear according to the general belief that the heart is the utmost important part of life. Other possible explanations include the doubt about the safety of this procedure and the benefit that they will receive. Then, any misunderstanding should be corrected and this technique should be encouraged when clinically indicated.


Laboratory diagnosis of congenital and maternal rubella infection: a review. Physicians are aware of the congenital rubella syndrome. Serodiagnosis is usually used to detect rubella infection in pregnant women and their fetuses. Although being considered the cornerstone of serodiagnosis, the hemagglutination inhibition test is gradually being replaced by new more convenient methods. Tests to detect IgM eliminate the need for paired sera to diagnose acute rubella infection. However, because of the possibilities of false positive, IgM results should be interpreted with caution. Detection of IgM in cord blood and new genetic technology made the diagnosis of infection in utero possible. The evidence of reinfection in people considered to be immune is abundant; however, discovering new antigenic determinants correlating with immunity may solve the problem and a new vaccine and antibody test that is truly associated with immunity will be available in the future.


Rapidly progressive glomerulonephritis in Thai children. Sixteen children with extensive crescentic glomerulonephritis and rapid renal deterioration were selected from 476 patients with glomerulopathy for study. The patients (1-14 yr, M:F = 5:11) presented with edema, oligoanuria, hypertension, gross hematuria and uremic symptoms in 81, 62, 62, 56 and 50 per cent, respectively. The mean Scr was 804 (+/- 436) micromole/L and BUN 38 (+/- 13.4) mmole/L. Anemia was found in 100 per cent, hematuria in 100 per cent, heavy proteinuria 75 per cent, hypoalbuminemia 40 per cent, hypercholesterolemia 38 per cent and low C3 40 per cent. The underlying causes of RPGN included idiopathic 9, PSAGN 6 and LE 1. Eight patients recovered with normal or slightly elevated Scr while the diseases progressed to ESRD in 8 patients. Idiopathic RPGN and extensive (greater than 80%) crescentic glomerulonephritis correlated with a poor prognosis.


Combined Sarcocystis and gram-positive bacterial infections. A possible cause of segmental enterocolitis in Thailand. Between 1981 and 1990, 22 intestinal specimens surgically resected due to segmental enterocolitis were collected and examined. Grossly, the specimens were classified into 3 groups 1) Acute inflammation with hemorrhage and necrosis 2) Constrictive lesion 3) False diverticulum with perforation. Mostly, there was unisegmental involvement, distributed in jejunum, ileum and ileocolon. Microscopically, small parasitic structures, interpreted to be unconventional excystation stage of Sarcocystis hominis, (Railliet and Lucet, 1891) Dubey 1976, were present on the luminal border and within the crypt-lining epithelial cells. At the ulcerated area, tissue invasion by Gram-positive bacteria were always seen and considered as second pathogen. Source of the parasite was likely from cyst-containing beef available in markets, (Bos indicus and Bubalus bubalis) along with consumption of undercooked beef. Antismooth muscle antibody, IgG class, with the titer ranging from 1:16-1:256 were detected in 45 per cent of the patients. This is considered as autoimmunity against intestinal smooth muscle damaged previously from subclinical inflammatory condition. Present information suggests a long-standing existence of Sarcocystis in the patients' intestine, associated with Gram-positive bacterial infection, as the mechanism producing segmental enterocolitis found in the Central region.


Tuberculous infection of the hand and the wrist. Twenty cases of tuberculous infection of the hand and the wrist from the division of plastic reconstructive surgery over the past 17 years. There were fourteen males, and six females. The ages of the patients ranged from 10 years to 80 years, with an average age of 50.1 years. The follow-up time was not less than 3 years. The characteristic manifestation of this diseases was insidious onset, and run chronicity. Painful swelling of the wrist and fingers as well as increased sedimentation rate were frequent findings. However, confirmed histopathological diagnosis is essential. Surgical debridement together with triple anti-tuberculous drugs are recommended. Triple drugs therapy should be given for not less than two years to prevent drug resistance and recurrence of the disease.


The preparation of lyophylised of fetal membrane for biological dressing. The preparation of lyophylised fetal membrane was performed between November 1982 and May 1984, and the membrane was applied to a variety of wounds. The result of the study was impressive, the biologic dressing property did fairly well, and the utilization of this fetal membrane was convenient in time and place.


Fungal sinusitis the important role of the histopathology in the clinical management. Four cases of fungal sinusitis are reported. These include one case of aspergillus sinusitis alone, one case of combined aspergillus and paecilomyces sinusitis, and two cases of mucormycotic (zygomycotic) sinusitis. Although fungal sinusitis appears to be rare, it can pose difficulty in clinical diagnosis and we have demonstrated how the pathologist can help to alert the otolaryngologists of possible fungal sinusitis. Since the histopathological examination is important, a specimen for biopsy is mandatory.


Development of immune-complex glomerulonephritis and amyloidosis in Syrian golden hamsters infected with Opisthorchis viverrini. Renal disease associated with Opisthorchis viverrini infection was investigated in Syrian golden hamsters. On the fourth week after infection with 100 viable metacercariae; anti-tegumental membrane antibodies were detected in the sera by immunofluorescence antibody technic and by enzyme-linked immunosorbent assay. Six weeks after infection tegumental and anti-tegumental membrane immune-complex and amyloid fibrils were found in the glomeruli. Amyloid was characterized to be AA protein. Acute proliferative glomerulonephritis associated with the brightest immune-complex deposits developed in week 8 after infection. Intensity of immune-complexes in all glomeruli were reduce gradually thereafter and replaced by amyloid. Progressive obsolescence of the glomeruli, tubular atrophy, interstitial inflammation and fibrosis associated with massive proteinuria and deterioration of renal function appeared in week 10 after infection toward the end of the experiment in week 38 after infection.


Sarcocystis infection and actinomycosis in tumorous eosinophilic enterocolitis. Intramural masses were resected from jejunum and ileocecal portion of a 49-year-old, female patient with partial gut obstruction. Histopathological examination indicated the masses to be tumorous eosinophilic enterocolitis. Recent and late development phases of Sarcocystis in relation to bradyzoite infection have been observed and considered to be responsible for eosinophilic inflammation. Concomitant intestinal actinomycosis, known to produce tumorous lesion without eosinophilia, appears as an attractive natural model in producing tumorous eosinophilic enterocolitis. Pertaining to parasitic development, it is suggested that persisting sporulated oocyst may undergo spontaneous excystation in the host's intestinal wall, along with complex sporogony.


Causes of perinatal death defined by autopsy at Ramathibodi Hospital. Most causes of death during the fetal period are still unknown in all birth weight groups. Intrauterine anoxia evidence by clinical data and autopsy finding is the leading known cause in infants 1,001-2,500 g and over 2,500 g. In the early neonatal period in infants 1,001-2,500 g and over 2,500 g, the most common cause of death is congenital malformation which was also found as the main cause in the late neonatal over 2,500 g group. More than half of the deaths in the late neonatal period 1,001-2,500 g group, were caused by infection. Congenital syphilis and tetanus neonatorum which existed in the first study were not found in this study which reflects improved medical care.


Prognostic factors of thyroid cancers in Ramathibodi Hospital. The need to create different prognostic models for different populations is obvious after the findings that significant prognostic factors can change from one population to another. The purpose of this study is to fit a linear logistic model to a data set of Thai patients with thyroid cancers to find important prognostic factors and their effects on short-term mortality. Among the 89 cases selected, 20 died within 4 years after initial diagnosis and 69 survived more than 4 years. Age at diagnosis, sex, histological type and differentiation, microscopic vascular invasion, and extent of tumor spreading were included as independent variables. These variables were selected into the model by step-down selection procedure. Age at diagnosis was found to be the most significant prognostic factor followed by differentiation, vascular invasion and extent of spreading, respectively. However, vascular invasion appeared to exert the strongest impact on the prognosis with the risk of death increasing 62 fold for those showing microscopic evidence of this parameter. The odds ratios for the extent of spreading, age at diagnosis and differentiation were 7.5, 1.1 and 0.02, respectively.


Changing terminology and screening recommendations in cervical cytology screening programs. In summary, we have presented proposed new diagnostic terminology and screening frequencies for cervical cytology with some of the surrounding debate. As Thailand develops its own cervical screening program for squamous cell carcinoma, an awareness of these new recommendations may help in the design of a local program in the most cost effective manner.


Blue nevus of the uterine cervix.

Blue nevus of the uterine cervix. A case of an incidentally detected blue nevus of endocervix is presented. The nevus cells contained premelanosome and melanosomes. Pinocytotic activity, and interrupted basal lamina were disclosed by electron microscopic study. The histogenesis of these nevus cells from perineurial cells is discussed.


Fatal paraquat poisoning: a light microscopic study in eight autopsy cases. Eight autopsy cases of paraquat poisoning from 1980 to 1990 were studied by light microscopy. An attempt was made to correlate the severity of poisoning, as assessed by the blood paraquat concentrations and the time between ingestion and treatment, with the survival periods and pathological changes. Six of the patients were male. The mean age was 21 years (range 12-33 years). The blood paraquat concentrations on admission ranged from 0.04 to 4.27 micrograms/ml. The survival periods were between 26 hours and 59 days. The main causes of death included circulatory collapse in one patient with 26 hours survival, and acute alveolar injury of the lungs and acute tubular necrosis or diffuse cortical necrosis of the kidneys in 4 patients who survived less than 7 days. Pulmonary proliferative changes leading to respiratory failure were detected in the remaining patients, who survived 11, 17, and 59 days. The liver revealed bile duct injury in the portal areas, centrolobular cholestasis, fatty metamorphosis, and inconspicuous centrolobular hepatic necrosis. The adrenal glands showed diffuse cortical necrosis in 3 severe cases. Mild acute pancreatitis was evident in one case. The brain was edematous with or without focal minimal hemorrhages. Toxic myocarditis, myositis, and aplasia of erythropoiesis, as previously described, were not present in this study. The severity of poisoning seems to correlate reversely with the survival periods and directly with degrees of pulmonary damage and adrenal cortical necrosis.


Does indication sheet reduce unnecessary urethral catheterization? The study on the effect of indication sheet on the decision of doctors in ordering urethral catheterization was done in thirteen hospitals randomly selected from all regions of Thailand. 16,959 patients in medical and surgical wards were included between April and May 1989. The rates of urethral catheterization did not change by the influence of indication sheet. However, urethral catheterization without proper indications was reduced from 27.0 per cent in the control group to 14.3 per cent in the experiment group. The indication sheet was accepted in 96.5 per cent of the occasions when doctors prescribed urethral catheterization. The indication sheet changed the doctors' decision and hence reversed the order in 3 events (0.8%). It is concluded that indication sheet was well accepted by doctors and could reduce urethral catheterization without proper indications.


Comparison of costs for disposable and reusable syringes and needles in Siriraj Hospital. The costs for disposable and re-usable syringes and needles were compared in Siriraj Hospital, in July 1988. Data were collected from all wards regarding number of items used or replaced. Labour costs for recycling re-usable items were estimated by close observation. The costs for disposable and re-usable syringes and needles were 498,039.50, 193,874.45, 69,410.00 and 27,366.95 baht respectively. It can be concluded that re-usable items cost only 36 per cent of disposable ones. It is evident that re-usable syringes and needles should be appropriate for hospitals in Thailand at present.


An alternative model for surveillance of nosocomial infections. A modified method of administration of surveillance N.I. was introduced in Prapokklao Hospital, Chanthaburi, Thailand. Head nurses from all wards were recruited to survey N.I. By education, supervision and encouragement, the efficiency in surveillance gradually rose. The attack rate of N.I. by this method was only 2 per cent in 1986 when the project was started. The rate rose to 5.3 per cent 2 years later. This model for surveillance shares the burden of the I.C.N. who are critically undermanned. The method was well accepted. Co-operation by medical personnel increased. This model is cost-effective and can be adopted by many hospitals in Thailand.


Pre-operative shaving and wound infection in appendectomy. The study on the effects of shaving the skin on wound infections after appendectomy was done in 80 patients in 1988 in Siriraj Hospital. Patients were divided randomly into two groups, 40 patients each, a control and an experiment group. The control group had their skin shaved and the experiment group did not. Data showed no difference in: demography, preoperative admission time, interval between skin preparation and surgery, thickness of subcutaneous tissue, operating time, and suture materials. Shaving of the skin resulted in no alteration in bacteria found on the skin, on the walls of the wound before closing. Stitch abscesses were the only wound infection found in 3 patients in each group. It is concluded that skin shaving, though it did not increase wound infection rate, had no beneficial effect on wound infection in appendectomy.


Cross-infection of gentamicin-methicillin-resistant Staphylococcus aureus in a male surgical ward at Rajavithi General Hospital. Between January and December 1987, gentamicin-methicillin-resistant strains of Staphylococcus aureus (GMRSA) were isolated from 7 patients in a male surgical ward at Rajavithi General Hospital. Six patients developed significant infection which included sepsis (2), pneumonia (1), infection in the eye, ear and wound (1), wound infection (2), and one patient had GMRSA isolated from his sputum. The strains were untypable with standard phage type and were resistant to methicillin, gentamicin, amikacin, kanamycin, streptomycin, tetracycline, erythromycin and chloramphenicol, but susceptible o vancomycin and cotrimoxazole. GMRSA were also isolated from bed-rail and the used rubber gloves left in the affected room. The GMRSA strains contained 5 plasmids of molecular weight of 18, 11, 2, 1.8 and 1.7 Md. The 2Md plasmid coded for chloramphenicol resistance and the 1.8 Md plasmid for erythromycin resistance.


Nosocomial infection control activities in Thailand 1989. The study on the infection control activities was done in 89 general regional and community hospitals. Seventy-seven hospitals responded to the questionnaire (87%). All hospitals had set up infection control committees. Infection control nurses had been appointed in 84 per cent; 45 and 39 per cent were part-time and full-time ICNs respectively. Reports of surveillance were sent to the committees in 74 of the hospitals. Doctors took part in infection control in 75 per cent of the hospitals. Isolation units were available in 86 per cent and incinerators were installed in 13 per cent of the hospitals. These results indicate that the allocation of manpower and resources are not sufficient for effective nosocomial infection control.


Precaution against nosocomial spread of cholera in Udornthanee Hospital. From February to April 1988, there was an outbreak of cholera in Udornthanee Province. One hundred and twenty-four culture-documented cases were admitted into Udornthanee Hospital. Prevention of nosocomial spread of V. cholerae was done by the implementation of proper practices, surveillance culture and routine surveillance. There was no nosocomial spread of V. cholerae to patients or medical personnel. It was also shown that these practices were effective in prevention of contamination of the environment. It is concluded that simple measures are effective in the prevention of spread of V. cholerae in health care settings.


Hospital acquired Janthinobacterium lividum septicemia in Srinagarind Hospital. Nine patients admitted to the intensive care unit, Srinagarind Hospital, who had septicaemia by J. lividum were reported. Seven patients died, one directly of septicaemia, despite intensive antimicrobial therapy. Investigation revealed that the sources of infection were: special mouth wash solution, distilled water and normal saline used in the ward. After changing to uncontaminated solution and more meticulous care of medical equipment, there was no evidence of the micro-organism after one year follow-up.


Characteristic findings on the standard 12-lead ECG in patients with the fasciculoventricular Mahaim fiber. Standard 12-lead electrocardiograms with a Q wave in lead V1 were obtained from 32 subjects without organic cardiac disease and analyzed for features that might characterize an abnormal atrioventricular conduction through the fasciculoventricular Mahaim fiber. Following an infusion of ajmaline, the Q wave in V1 vanished abruptly and changed to an rS pattern in the 12 ajmaline responders. Discriminant analysis was performed to distinguish the ajmaline responders from the others. The explanatory variables were number of precordial leads with the abnormal Q wave, existence of the septal q waves, existence of the slurring of the Q wave in V1, existence of clockwise rotation, and existence of high voltage (RV5 + SV1 > 3.5 mV). Three variables, the absence of the septal q waves, the presence of the slurring, and the absence of clockwise rotation, were found to predict a positive response to ajmaline (discriminant probability = 77%). These findings associated with the Q wave in V1 suggest that the fasciculoventricular fiber may be present.


Variability in ECG computer interpretation. Analysis of individual complexes vs analysis of a representative complex. Variability in the electrocardiogram (ECG) can be due to extrinsic noise or can be caused by intrinsic factors, such as changes in the volume conductor or in the heart itself. Computer programs for the interpretation of the ECG base their diagnostic classification on one set of measurements that is derived from a representative PQRST complex or that is computed by taking the median from the measurements for each complex in the recording. However, these methods may fail to do justice to the intrinsic variability that may be present in the ECG. An alternative method is proposed: derive a set of measurements from each complex in the recording, classify each individual complex separately, and then combine the individual classifications into one final classification. This procedure has been evaluated on a validated database (n = 1,220) using an ECG computer program. Total accuracy against the clinical evidence increased from 69.8% for the interpretations of the averaged complexes to 71.2% for the combined interpretations of the individual complexes (p < 0.001). The effect of beat-to-beat variation on the measurements and classifications is demonstrated and the influence of extrinsic and intrinsic variability is assessed.


ECG changes and cardiac arrhythmias in chronic renal failure patients on hemodialysis. Serial 12-lead electrocardiogram (ECG) recordings and 24-hour Holter monitoring were carried out in 39 patients with chronic renal failure, starting just before a routine dialysis session. In an attempt to identify risk factors for cardiac arrhythmias, the results obtained from each patient were correlated with a variety of clinical, hematological, and biochemical data. All patients exhibited ECG changes, which were most pronounced during the first 2 hours of dialysis. The most frequent of these changes were a decrease in T wave amplitude and increase in Tmax time (all patients), an increase of QRS amplitude (61% of patients), shortened or prolonged QTc interval (61%) and ischemic-like ST-T changes (22% and 39%, respectively). Potentially clinically significant arrhythmias occurred in 12 patients (31%) of which 8 were supraventricular, 3 were combined ventricular and supraventricular, and 1 was pure ventricular. The only clinically identified risk factor for complex ventricular and supraventricular arrhythmia was advanced age. The arrhythmia and nonarrhythmia groups differed significantly in their predialysis hematocrit, O2 content, serum urea, and osmolarity, and in their postdialysis serum phosphorus and osmolarity. The results indicate that patients with chronic renal failure frequently exhibit ECG changes and a high incidence of ventricular and supraventricular arrhythmias, which may be prognostically significant, during and after hemodialysis.


Use of the 12-lead ECG to detect myocardial reperfusion and salvage during acute myocardial infarction. In this era of thrombolytic therapy, the standard 12-lead electrocardiogram (ECG) is easily available and noninvasive and could provide indicators of myocardial reperfusion and salvage. Previous reports have proposed that a decrease of total ST-segment elevation of > or = 20% from the pre- to the immediate posttreatment ECG is indicative of reperfusion, and that a > or = 20% decrease from the initial infarct size predicted by ST-segment deviation on the admission ECG to the final infarct size estimated by QRS score on the predischarge recording is indicative of myocardial salvage. This prospective study of 29 patients with myocardial infarction and angiographically documented reperfusion shows that the > or = 20% threshold for ST resolution achieved 79% sensitivity and 70% specificity in patients receiving intravenous therapy and 90% sensitivity in those receiving rescue intracoronary therapy. However, it should be noted that 21% of patients with successful intravenous therapy failed to achieve even this threshold of ST resolution. Regarding myocardial salvage, 63% of patients receiving intravenous and 90% of those receiving rescue intracoronary therapy achieved the threshold of > or = 20% decrease in infarct size.


Effects of premature excitation and tachycardia on the spatial distribution of refractoriness and propagation of excitation in a computer model. In this study, the spatial pattern of refractoriness and its effects on propagation of excitation during premature responses and tachycardia have been investigated using a computer model. The model simulated propagation, cycle length-dependent refractoriness, and slow propagation during the relative refractory period. Findings showed slow propagation near the origin of premature responses resulting in longer cycle lengths distal to the slowing. The nonuniform cycle lengths terminated by a premature response also represented the onset of the subsequent cycle, so the pattern of refractoriness was altered after both the premature and following cycle. This occurred even though cycle length affected only the immediately following refractory period in the model. The effect of nonuniform cycle lengths during a premature response on refractory periods after the subsequent response occurred with all cycle lengths of the later response. When the cycle length of that and further responses was sufficiently shortened to result in slowed propagation, changing spatial patterns of refractoriness and propagation occurred. The findings are evidence that responses with slow propagation during incomplete recovery of excitability can affect conduction velocity and refractoriness during multiple subsequent cycles. These effects are likely to occur in the heart but are modified by features such as sustained effects of cycle length on refractoriness, anisotropy, and electrotonic interactions.


Resting and ambulatory ECG predictors of mode of death in dilated cardiomyopathy. With the purpose of verifying whether the electrocardiogram (ECG) pattern alone can predict the mode of death in dilated cardiomyopathy, data from 12-lead ECGs and 48-hour arrhythmia monitoring were evaluated in 67 patients with dilated cardiomyopathy. During a mean follow-up period of 3 +/- 2 years, death from congestive heart failure occurred in 18 patients (27%), whereas 10 (15%) died suddenly (NS). Multivariate analysis showed that left bundle branch block (p < 0.001) and left atrial enlargement (p < 0.001) were independently related to death from congestive heart failure. Ventricular arrhythmias of Lown grade 4A or 4B (p < 0.001) and repolarization time, as assessed by QTc-QRS interval (p < 0.05), were independent predictors of sudden death. It is concluded that ECG features alone may be helpful for risk factor characterization of dilated cardiomyopathy patients, provided that multiple ECG criteria are utilized at time of diagnosis.


Relationship of QRST isointegral maps during simulated left bundle branch block to impairment of left ventricular function due to myocardial infarction. The clinical usefulness of QRST isointegral maps for assessing left ventricular (LV) dysfunction due to myocardial infarction (MI) in patients with MI in the setting of simulated left bundle branch block (LBBB) was investigated. Isointegral maps were recorded during sinus rhythm and right ventricular pacing, which simulated LBBB, in 62 patients with MI and 26 patients without MI. An abnormal decrease in the QRST value in the isointegral map was assessed by the difference map that indicated a "-2 SD area" where the QRST integral value was less than the normal range (mean - 2 SD) calculated from 608 normal individuals. The isointegral maps during the two activation sequences were similar in patients with and without MI (r = 0.87 and 0.92, respectively). The sum of QRST integral values less than the normal range (sigma DM) during simulated LBBB correlated significantly with the asynergy index, derived from left ventriculographic data (r = 0.81, p < 0.01). LV dysfunction (asynergy index > or = 2) was diagnosed in simulated LBBB with a sensitivity of 81%, specificity of 77%, and diagnostic accuracy of 80% when the criterion that LV dysfunction is present if the number of lead points in the -2 SD area exceeds 4, and a sensitivity of 71%, specificity of 81%, and diagnostic accuracy of 74% if sigma DM exceeds 200 mVms was used. The findings demonstrate that isointegral maps may be useful in assessing LV dysfunction due to MI in patients with MI and LBBB in addition to detecting the presence and site of MI in these patients.


Small differences among body surface and epicardial QRST integral maps recorded during normal activation and experimentally simulated left bundle branch block or preexcitation in canine hearts. QRST integral maps were constructed from 87-lead body surface electrocardiograms (ECGs) and from 45-lead epicardial electrograms during artificial pacing, which simulated left bundle branch block (LBBB) and Wolff-Parkinson-White syndrome in 12 dogs. Although the ECGs and electrograms differed in configuration for each conduction model, the body surface and the epicardial QRST integral maps showed only small differences. Correlation coefficients (r) and root mean square differences (rms) were calculated to assess quantitatively the similarities in the QRST integral maps among the different conduction models. Mean r values between the normal conduction and the left bundle branch block models were 0.95 in the body surface maps and 0.89 in the epicardial maps. Mean r values between the normal conduction and the Wolff-Parkinson-White ECG models were 0.97 in the body surface maps and 0.91 in the epicardial maps, and rms values were small enough. The small differences were also verified by the difference maps and by paired t tests. QRST integral maps on the epicardium and on the body surface were largely independent of altered activation sequences in both the left bundle branch block and the Wolff-Parkinson-White ECG models.


Comparison of ST depression recorded by Holter monitors and 12-lead ECGs during coronary angiography and exercise testing. Data from previous studies are debatable regarding whether Holter monitors are a reliable electrocardiographic indicator of ischemia, for which the 12-lead electrocardiogram (ECG) is the standard. Simultaneous 12-lead and Holter ECGs were performed on 30 patients with typical angina pectoris during coronary angiography or exercise testing. ST depression recorded by both methods was directly compared, using the 12-lead ECG as the reference. The Holter tapes were also scanned by two automated ST analysis programs and the results were compared to 12-lead ECGs. Only 66 of the 178 12-lead ECG ST depression events were also present on the Holter recordings (37.1% Holter sensitivity). ST depression was underestimated by the Holter recordings compared to the 12-lead ECGs (p < 0.0001). The majority (67.0%) of ST depression events identified by one computer program were false positive events. The degree of ST depression was overestimated compared to 12-lead ECGs by the second program (p = 0.0033). Holter-detected ST depression may not be a reliable ECG indicator of myocardial ischemia.


The effect of stress and fatigue on cardiac rhythm in medical interns. Twenty-four-hour ambulatory electrocardiographic monitoring was used to determine the incidence of arrhythmia while on-call and its relationship to stress and fatigue in 20 healthy medical interns. Mitral valve prolapse was present in 8 of 19 interns (42%). Heart rates ranged from a maximum of 103-167 beats/min (135 +/- 16) to a minimum of 38-61 beats/min (47 +/- 5). Interns had at least one episode of sinus tachycardia/h during 57% +/- 21% (range, 8-88%) of their hours on-call. Atrial premature beats (APB) were present in 19 of 20 (95%) and ventricular premature beats (VPB) in 12 of 20 (60%) subjects. APB/h ranged from 0 to 1.2 (0.4 +/- 0.3) and VPB/h from 0 to 23 (2 +/- 6). Three interns had multiform VPB and two had ventricular couplets. More APB/h occurred in interns under greater stress (0.5 +/- 0.4/h vs 0.3 +/- 0.1/h, p < 0.05) and combined stress and fatigue (0.6 +/- 0.4/h vs 0.2 +/- 0.2/h, p < 0.01). More VPB/h (5 +/- 9/h vs 0.5 +/- 0.6/h, p < 0.05) and higher (Lown) grade ventricular ectopy (2.3 +/- 1.6 vs 0.8 +/- 1.1; p < 0.05) occurred in interns under greater combined stress and fatigue. Mitral valve prolapse, sleep deprivation and caffeine intake were not associated with increased arrhythmia. The authors conclude that (1) rapid sinus tachycardia is frequent in interns while on-call and (2) interns experiencing greater stress and fatigue have more APB/h, VPB/h, and higher grade ventricular ectopy. These data support the notion that stress and fatigue may contribute to arrhythmia in healthy normal subjects.


Autodecremental pacing for the interruption of ventricular tachycardia and atrial flutter. The efficacy and safety of autodecremental pacing (ADP) to interrupt ventricular tachycardia (VT) and atrial flutter was examined. Once tachycardia was recognized, ADP was initiated using a short train of stimuli with gradual shortening (3%) of the interstimulus interval. ADP was applied to 13 consecutive patients during 75 episodes of VT (mostly following induction by ventricular stimulation). Successful interruption of VT occurred in 88% of the episodes. In 6 episodes (8%), ADP resulted in ventricular fibrillation and in 3 episodes VT was unaffected by ADP. The only significant discriminator between the failure or success of ADP was the rate of VT. ADP was also applied to 17 consecutive patients with an atrial flutter that was resistant to conventional antiarrhythmic agents. Successful conversion of atrial flutter to sinus was seen in only 8 patients (47%). A temporary acceleration to atrial fibrillation appeared in 3 patients (18%), and in 6 patients atrial flutter was unaffected by ADP. ADP was successful in 70% (7/10) of patients with type 1 (< 300 beats/min) atrial flutter. The authors conclude that ADP is beneficial in the interruption of VT and atrial flutter in a selected group of patients, especially with a slower rate of tachyarrhythmia (atrial rate during atrial flutter < 300 beats/min and ventricular tachycardia < 180 beats/min).


A 10-year follow-up study by orthogonal Frank lead ECG on patients with progressive muscular dystrophy of the Duchenne type. A 10-year follow-up study by orthogonal Frank lead electrocardiography was performed on 25 patients with progressive muscular dystrophy of the Duchenne type (DMD). With advancing age, no apparent changes were observed in the duration and amplitude of the P wave or in the PR interval, whereas the duration of the QRS complex tended to increase. The amplitudes of the R wave in lead X (Rx) and lead Y (Ry) tended to decrease from 1.75 +/- 0.90 and 1.96 +/- 0.59 mV to 0.80 +/- 0.63 and 1.39 +/- 0.62 mV (p < 0.01), whereas the amplitude of the S wave in lead X tended to increase from 0.24 +/- 0.23 mV to 0.53 +/- 0.36 mV in 10 years after initiation of the study (p < 0.01). It is noteworthy that the Ry amplitude began to decrease markedly from the seventh year after the initiation of this study, whereas the Rx amplitude showed a gradual and unceasing decline through the 10-year period. Observation of the sequential changes of the QRS loops in three planes clearly demonstrated that the electrical force tended to decrease in the leftward and inferior directions and increase in the rightward direction. It is of interest that the frequency of occurrence of the deep Q wave was found to be quite high even in the early stages of DMD and that it did not display a direct relation to the sequential evolution of this disease. It can be concluded that observation of the sequential changes in the QRS complex allows estimation of the extent and direction of myocardial involvement in DMD.


Ultra-high-resolution scanning electron microscopy of vaccinia virus and its recombinant carrying the gag gene of human immunodeficiency virus type 1. FL cells infected with vaccinia virus or its recombinant carrying the gag gene of human immunodeficiency virus type 1 (HIV-1) were examined by ultra-high-resolution scanning electron microscopy. Virions, whether located extracellularly or intracellularly, had a brick-shaped or watermelon appearance as a whole. Extracellular virions observed on the surface of infected cells had variable surface ultrastructures depending on the manner in which particular virions were wrapped in cell membranes. Most of the intracellular naked virions adherent to the inner face of cell surface membranes clearly exhibited ridgy, rod-shaped or globular surface structures on their surface. HIV-like particles with a diameter of about 100 nm and virions of vaccinia virus were both observed distinctly on the surface of FL cells infected with the recombinant virus.