Effect of herpes simplex virus type 1 infection on cytokine gene expression in activated murine peritoneal macrophages. The intrinsic resistance to herpes simplex virus type 1 (HSV-1) of murine peritoneal macrophages (PM phi) obtained after in vivo infection of different stimuli has been investigated and shown to vary depending on the state of M phi activation. Activation of M phi by C. parvum (CP-M phi) or by an avirulent strain of S. typhimurium (Sal-M phi) increased the permissiveness of M phi to HSV-1 infection as evidenced by increased HSV-1 immediate early (IE) gene expression, synthesis of IE proteins, and the degree of cytopathic effect. HSV-1 infection was also found to sharply reduce the level of IL-1-beta mRNA in CP-M phi) and Sal-M phi, and the level of IL-3 mRNA in infected Sal-M phi, as measured by northern blot hybridization. Barely detectable levels of IL-beta mRNA were found in Sal-M phi after infection with HSV-1 when the polymerase chain reaction (PCR) assay was used to confirm the reduction of IL-1-beta mRNA. These data suggest that HSV-1 infection can modulate gene expression of some cytokines in the activated M phi.


Diagnostic virology--then and now.

Diagnostic virology--then and now. In the past five years, technologic advances in the shell vial assay and expanding availability of rapid membrane EIA tests have allowed over 90% of the viruses detected in our laboratory to be reported within 24 h postinoculation. PCR technology promises to add a new practical dimension to diagnostic virology especially for the detection of viruses in CSF, tissues, and blood. Extension of these diagnostic capabilities from investigative protocols to general laboratories for routine use will be our biggest challenge and be based on considerations of cost, licensing, and availability of this technology in "kit" formats.


Genetically engineered bacteria to identify and produce anti-viral agents. We have prepared a strain of Escherichia coli that expresses both the HIV protease and a Tet protein which has been modified to contain the HIV protease recognition sequence. When the protease is expressed, the bacteria will not grow in the presence of tetracycline. However, when the protease is inhibited the bacteria can grow in tetracycline containing media (Block and Grafstrom 1990). We have selected spontaneously arising Tet resistant mutants and have screened them for those that could be producing an inhibitor of HIV protease. The problems in the construction of this strain and the characterization of the various Tetr mutants are discussed.


Molecular characterization of HIV-2 (ROD) protease following PCR cloning from virus infected H9 cells. A 450 nucleotide sequence corresponding to the nucleotides 1931-2380 of the viral genome (8) was amplified by polymerase chain reaction (PCR) using template DNA prepared from HIV-2 (ROD) infected H9 cells. The sequence codes for HIV-2 protease and its N-terminal flanking peptide. An identical DNA sequence was obtained from three independent PCR amplifications, which differs from the published sequence of HIV-2 (ROD) in 7 nucleotides scattered throughout the region of the cloned DNA. The cloned DNA was expressed in E. coli cells and resulted in the synthesis of a correctly processed HIV-2 protease, which is enzymatically active. Therefore, none of the seven nucleotide changes, which resulted in two amino acid substitutions, affect the autoproteolytic or trans-cleaving activities of the HIV-2 protease.


Analysis of the diminished skin perfusion in elderly people by laser Doppler flowmetry. Clinical observations suggest an age-associated decline in skin perfusion but there are few quantitative in vivo data on skin perfusion at various ages. We studied skin perfusion of the dorsum of the foot by determining the capillary blood flow velocity (CBFV) expressed in millivolts (mV), using laser Doppler flowmetry, in ten young and 12 elderly men. Our data revealed that, at 32 degrees C skin temperature, the CBFV oscillations (vasomotions) are of higher median amplitude in young people than in elderly subjects: 9.4 mV (95% CI, 8.8-10.0 mV) and 4.6 mV (95% CI, 4.1-7.4 mV), respectively (p less than 0.05). The vasomotion frequency was similar in both age groups. At 44 degrees C skin temperature, the median CBFV peak in the young was 163 mV (95% CI, 128-192 mV), as opposed to 102 mV (95% CI, 92-124 mV) in the aged subjects (p less than 0.0005). The median increment in CBFV, driven by every heart beat, was also higher in the young age group: 86 mV (95% CI, 76.4-96.0 mV) compared with the elderly group: 63 mV (95% CI, 50-72 mV, p less than 0.005). Considering the fact that the magnitude but not the pattern of skin perfusion varied between the two groups, we conclude that ageing is associated with loss of capillary plexus functional units, and therefore the skin perfusion is lower in aged people.


Gait on a shoestring: falls and foot separation in parkinsonism. A novel device for monitoring gait, which can be used in confined spaces, is described. In addition to distance/time assessment of gait, it measures foot separation whilst walking. A field trial illustrates its potential in the investigation of falls.


Nosocomial diarrhoea due to a single strain of Clostridium difficile: a prolonged outbreak in elderly patients. An outbreak of diarrhoea occurred in an acute geriatric ward of a hospital (A). It affected six patients initially and was found to be due to a single strain of Clostridium difficile. There was little evidence for asymptomatic carriage of this strain or others in the hospital patients. The following three months saw an increase in the number of symptomatic cases of C. difficile disease in two peripheral hospitals, B and C. Patients had been moved from the outbreak ward to these hospitals. Of 18 cases in hospital B all 15 isolates saved for typing were of the 'outbreak' strain. Of three cases occurring in hospital C, only one was the 'outbreak' strain (a relapsed patient who was part of the original episode). There were seven further cases in geriatric and medical wards of hospital A. All six typed isolates were also the outbreak strain. By chance, four isolates from hospital A and four from hospital B pre-dating the outbreak were also available for typing and seven of these were found to be identical to the outbreak strain. This suggests that one strain of C. difficile was endemic in geriatric and medical facilities on two sites and was responsible for nosocomial diarrhoea over at least one year. The problems of optimal management and infection control in this situation are discussed.


Radiographic pulmonary changes of gastro-oesophageal reflux disease in elderly patients. The aim of this study was to investigate the association of gastro-oesophageal reflux disease (GORD) with radiographic pulmonary changes. One hundred and thirty-seven patients aged over 60 years referred for endoscopy for abdominal symptoms were included in the study. In patients with any suspicion of GORD (n = 95), 24-hour oesophageal pH monitoring was carried out. All the patients were interviewed before the examinations. Chest radiography was performed in all patients. Odds ratio of respiratory symptoms was 8.7 (95% confidence interval 3.4-22.4) in patients with total reflux time of more than 10% compared with those who had total reflux time of less than 10%. In chest radiography, bilateral pleural adhesions and thickenings and bilateral parenchymal scars were significantly more common in patients with, than in those without, regurgitation or large hiatal openings. The occurrence of bilateral scars and pleural thickenings increased with the extent of gastro-oesophageal reflux in pH monitoring. Odds ratios of bilateral pleural thickening and pulmonary scars were 3.1 (95% confidence interval 0.8-11.5) and 5.8 (1.1-29.6) in patients with total reflux time over 10%, compared with patients who had normal total reflux time. The findings indicate that respiratory involvement is a characteristic feature of GORD in elderly patients.


Life satisfaction in elderly Nigerians: reliability and factor composition of the life satisfaction Index Z. Life satisfaction Index Z was administered to 945 persons aged 60 years and over in a community survey in rural and urban locations in South-Western Nigeria. Life Satisfaction Index scores correlated significantly with items on self-assessed health, loneliness, sex (women having a higher mean score) and location. Items that measure social contact, such as marital status, proximity of nearest child, and frequency of seeing close friends, did not correlate at a significant level. Factor analysis produced two factors on varimax rotation and an internal consistency value of 0.72 was obtained. These values are similar to some of those reported in other studies outside Africa.


Sleep-disordered breathing in elderly people and subjective sleep-wake disturbance. Sleep-disordered breathing and subjective reports of sleep-wake disturbances are both common in elderly people but previous studies investigating the relationship between the two have produced uncertain results. We hypothesized that there is no relationship between sleep-disordered breathing and subjective reports of sleep-wake disturbance. Ninety-three random-sampled retirement-village residents, mean age 77.6 years, were monitored overnight with a portable microprocessor-based system. The respiratory disturbance index (RDI) was used as a measure of sleep-disordered breathing. Subjects were interviewed regarding sleep-wake patterns and snoring history and the Mini Mental State Examination, Geriatric Depression Scale and Nelson Adult Reading Test were administered. The sleep-wake responses were entered into a principal components analysis. Two components, reflecting night-time and daytime disturbance, accounted for 34% of the variance. Multiple regression analyses were performed using RDI as a continuous dependent variable, and three predictor variables, night-time, and daytime disturbance and history of snoring. Together, these variables accounted for only 2% of the variance. We conclude there is no relationship between mild and moderate sleep-disordered breathing and subjective sleep-wake disturbance in this population.


Exocrine pancreatic insufficiency in presumed healthy elderly subjects. A pilot study on exocrine pancreatic function, using the 2-day para-aminobenzoic acid (PABA) test, was performed on 21 healthy elderly and 26 healthy young subjects. A PABA excretion index (PEI) less than 55%, indicating moderate to severe exocrine pancreatic insufficiency (EPI), was found in 19% of the elderly group (95% confidence limits 5-42%). While the mean value of the PEI was significantly lower in the elderly compared with the young group (Mann-Whitney Z = 2.8, p less than 0.01), there was no significant difference when the elderly subgroup with PEI less than 55% was excluded. There was no evidence of a generalized moderate to severe decline in pancreatic exocrine function with increasing age; a mild to moderate decline cannot be excluded.


Fluid balance in elderly patients following acute stroke. We studied the relationship between plasma osmolality, arginine vasopressin (AVP), and fluid input in patients during the acute phase of a first stroke. Fifteen consecutive patients were studied (median age 79) and their blood sampled on days 0, 1, 2, 3, 7 and 14. Plasma osmolality was related to fluid input over days 0-3 (p = 0.0013) and AVP over 14 days (p less than 0.001). Patients with a poor outcome had higher AVP concentrations (p = 0.02). Those on intravenous fluids received a higher volume (p less than 0.01) and had a lower plasma osmolality (p = 0.04). The results of this preliminary study indicate that a standard regime for fluid input is inappropriate.


The relationship of muscle and bone loss and activity levels with age in women. Quadriceps strength and cross-sectional area (CSA), spine bone mineral density (BMD), bone mass in the mid- and distal femur and physical activity levels were measured in 216 healthy British women. Muscle strength, CSA and bone in the distal femur decreased linearly from the third decade. Cortical bone at mid-femur was maintained until the sixth decade. Spine BMD decreased from the fourth decade with an accelerated period of loss in the sixth decade. There were significant positive relationships between quadriceps strength and bone mass at all three skeletal sites. With age kept constant, physical activity levels did not correlate with any of the muscle or bone indices. The force-generating capacity of the quadriceps decreased with age. These results suggest a relationship between the loss of muscle and bone with age which cannot be explained by declining physical activity levels.


Inappropriate medication is a major cause of adverse drug reactions in elderly patients. To determine the extent to which adverse drug reactions (ADRs) in elderly patients admitted to hospital are due to inappropriate prescribing, we examined 416 successive admissions of elderly patients to a teaching hospital. Interacting drug combinations and drugs with relative contra-indications (CIs) were common, but not as important in producing ADRs as drugs with absolute CIs or unnecessary drugs. Forty-eight patients (11.5% of admissions) were taking a total of 51 drugs with absolute CIs (3.8% of prescriptions). One hundred and seventy-five drugs were discontinued on or shortly after admission in 113 (27%) patients because they were deemed to be unnecessary. One hundred and three patients (27.0% of those on medication) experienced 151 ADRs of which 75 (49.7%) were due to drugs with absolute CIs and/or that were unnecessary, a significantly higher rate of ADRs (p less than 0.001) than observed for all prescriptions. Of 26 (6.3%) admissions attributed to ADRs, 13 (50%) were due to inappropriate prescriptions. The admission rate per prescription was significantly higher (p less than 0.001) for inappropriate than for appropriate drugs. We conclude that much drug-related morbidity in the elderly population may be avoidable, as it is due to inappropriate prescribing.


Autonomic cardiovascular responses to tilting in patients with Alzheimer's disease and in healthy elderly women. The cardiovascular responses to tilting and breathing were studied in 24 patients with late-onset Alzheimer's disease (AD) and 54 healthy control women aged between 75 and 96 years in order to study the parasympathetic and sympathetic heart-rate control. The cardiovascular response to tilting and breathing showed no age-associated decrease in the healthy control women. During rest, the AD patients had lower mean systolic and diastolic blood pressure but the same heart rate as the control patients. After tilting, the AD patients had a greater increase in heart rate, and the mean systolic blood pressure fell to 126 mmHg compared with 160 mmHg in the control women (p less than 0.001). After the initial acceleration, the following deceleration of the heart rate, an expression of parasympathetic nervous activity, was lower in the AD patients (p less than 0.001). The deep-breathing test showed no significant difference between the two groups, but the changes of acceleration and brake indices could indicate a dysfunction of the autonomic nervous system since the AD patients were not recumbent.


Diagnosis and treatment of croup.

Diagnosis and treatment of croup. Croup is a common childhood disease that has no specific diagnostic test. It must be differentiated from life-threatening diseases, such as epiglottitis, that demand specific interventions. A high degree of toxicity, the presence of dysphagia and the absence of cough help distinguish epiglottitis from croup. The usefulness and safety of visualization of the epiglottis in patients with croup are controversial. Clinical recognition of respiratory distress and failure is vital. Hypoxia is common. Pulse oximetry is helpful in the assessment of hypoxia, but readings do not correlate with clinical status or respiratory failure. Although studies have not proved that mist therapy is beneficial, the efficacy of racemic epinephrine is well documented. High dose corticosteroids have proved effective in the treatment of croup. Outpatient use of racemic epinephrine and steroids remains controversial.


Laryngeal tuberculosis revisited.

Laryngeal tuberculosis revisited. Although a rare entity, laryngeal tuberculosis must be a diagnostic consideration--along with laryngeal carcinoma--whenever patients present with prolonged hoarseness or painful dysphagia. This form of tuberculosis was once thought to be especially virulent and more infectious than other forms; however, severity was probably the result of the frequent association with advanced cavitary disease. Laryngeal tuberculosis usually responds well to multiple-drug antituberculous therapy.


Saline amnioinfusion for relief of variable decelerations. Fetal distress due to oligohydramnios can be treated with saline amnioinfusion. The technique is easily learned by physicians who know how to use intrauterine pressure catheters. Therapeutic and prophylactic indications for saline amnioinfusion include oligohydramnios, thick meconium-stained amniotic fluid, and fetal distress. Family physicians can use this new procedure to actively manage labor.


Unusual aspects of bacterial water-borne illnesses. Various water-borne bacteria can cause significant illness. Illness most often results from ingestion of contaminated water or seafood, with gastrointestinal entry of pathogens or their byproducts. The skin and soft tissues are also common entry points, either through trauma in or near the water, or by seawater contamination of an existing wound or break in the skin. Clinically significant water-borne illnesses are still rare. However, because humans are increasingly exposed to contaminated water sources through recreation or habitat, the rate of water-borne illnesses can be expected to increase. In patients who present with gastrointestinal illness or infections that do not respond to conventional therapy, water-borne pathogens should be considered in the differential diagnosis. A complete history, with attention to seafood ingestion and exposure to marine or freshwater life-forms, in conjunction with a high index of suspicion (especially in immunocompromised patients), will increase diagnostic accuracy in patients with water-borne illnesses.


Sports-related traumatic hyphema.

Sports-related traumatic hyphema. Traumatic hyphema is a common sports-related eye injury that can cause permanent visual loss. Although referral to an ophthalmologist is advised, the primary care physician is often responsible for making the diagnosis and initiating medical care. A careful history should be taken and a physical examination performed, with attention given to possible accompanying ocular injuries. Proper positioning of the patient and placement of a unilateral eye shield are the first steps in management. Therapy is aimed at preventing secondary hemorrhage, elevated intraocular pressure and corneal blood staining. Surgical intervention may be necessary to preserve vision. Prognosis depends on the size of the hyphema, the development of complications and the presence of associated injuries. Protective eye guards have been shown to be very effective in preventing traumatic hyphema.


Erythema nodosum.

Erythema nodosum. Erythema nodosum represents an inflammatory process in the septa between the subcutaneous fat lobules. The hallmark lesions are exquisitely tender, erythematous nodules that are distributed symmetrically on the extensor surfaces of the lower extremities. Erythema nodosum is considered an immunologic response, and a wide variety of clinically important antigens have been implicated. It may serve as a cutaneous marker for systemic diseases, such as tuberculosis, sarcoidosis, inflammatory bowel disease and lymphoma. The disease is diagnosed by deep elliptical biopsy and pathologic evaluation. The natural history is resolution with treatment of the underlying disorder or spontaneous regression of idiopathic disease.


Sclerotherapy for varicose and telangiectatic veins. Varicose veins of the lower extremities are present in approximately 20 percent of adults. They are often symptomatic and may contribute to the development of cutaneous changes of venous insufficiency. Sclerotherapy is a nonsurgical procedure to eradicate varicosities. It can be performed in the office and is more cost-effective than traditional surgical vein stripping, which requires hospitalization and a recuperation period. Sclerotherapy is relatively safe and effective and may be used to treat both varicose veins and telangiectatic "spider" veins of the lower extremities.


Identifying and treating patients with panic attacks. Panic disorder occurs in up to 3 percent of the population and can be socially, emotionally and occupationally disabling. A thorough clinical evaluation is crucial to exclude illnesses with similar presentations, particularly acute cardiac, gastrointestinal or neurologic disease. The noradrenergic nervous system is involved in panic attacks. These attacks are described as sudden, unexpected episodes of intense fear or discomfort, usually lasting five to 30 minutes. Appropriate medications include benzodiazepines, tricyclic antidepressants and monoamine oxidase inhibitors. Alprazolam and clonazepam are quickly effective in alleviating panic, but they cause significant symptoms upon discontinuation. The best-studied drug in the treatment of panic disorder is imipramine; like other tricyclic antidepressants, it can cause increased jitteriness early in treatment. Monoamine oxidase inhibitors may be particularly helpful in patients with panic disorder who exhibit social avoidance. Behavior therapy, an important component of treatment, involves the patient's confrontation of fears or phobias.


Thrombolysis-related early patency reduces ECG late potentials after acute myocardial infarction. To assess the effects of thrombolysis and reperfusion on late potentials after myocardial infarction, 101 patients (79 men, age 63.2 +/- 10.5 years) underwent signal-averaged ECG studies at 10.7 +/- 9.2 days, with the use of a 40 to 250 Hz band-pass filter. Patients were divided into four groups: (1) 54 patients treated with thrombolytic agents at 2.8 +/- 1.1 hours, with 81% "early" patency/reperfusion (TIMI grades 2 and 3); (2) 47 patients treated conventionally with 45% "late" patency/reperfusion; (3) 56 patients with patency (TIMI grades 2 and 3); and (4) 26 patients without patency (TIMI grades 0 and 1). A late potential was present when greater than or equal to 2 of 3 defined criteria were present. There was a significant difference in the incidence of late potentials between groups 1 and 2 (22% vs 43%, respectively; p = 0.048) and between groups 3 and 4 (18% vs 50%, respectively; p = 0.006). Late potentials also tended to occur less often after "early" than after "late" patency/reperfusion (12.5% vs 25%). The odds ratio for developing a late potential was 0.39 for thrombolysis versus no thrombolysis (p less than 0.05) and 0.22 for patency/reperfusion (TIMI grades 2 and 3) versus no patency/reperfusion (TIMI grades 0 and 1) (p less than 0.05). By analysis of covariance the effects of thrombolysis on late potentials were entirely explained by reperfusion. Thus the risk of late potentials after myocardial infarction is high but is reduced by thrombolysis and reperfusion. In addition, the effectiveness of "early" reperfusion appears to be greater than that of "late" but requires further clarification.


Coronary angioplasty of chronic occlusions: factors predictive of procedural success. In a retrospective study of 365 chronic total occlusions that were submitted for angioplasty, we studied the influence of 27 clinical, morphologic, and procedural variables as possible predictors of successful outcomes. Success rate was shown to be significantly influenced by the following variables: operator experience (41% in early patients, first 6 months; 73% in late patients, last 6 months of entire series; p less than 0.001), duration of occlusion (less than or equal to 1 month, 89%; 1 to 3 months 87%; greater than or equal to 3 months 45%; unknown 60%; p less than 0.001), morphology of occlusion (tapered, 83%; abrupt, 51%), length of occlusion (less than or equal to 15 mm, 71%; greater than 15 mm, 60%; p less than 0.001), and bridging collaterals (present, 29%; absent, 67%; p less than 0.001). None of the other clinical, angiographic, or procedural variables correlated with the success rate of coronary angioplasty. The calculated probability for an experienced operator (greater than 100 occlusions attempted) to successfully open an occlusion with favorable morphology (less than or equal to 1 month old, short, tapered, without bridging collaterals) is 99%. An attempt by the same operator to open an occlusion with unfavorable structure (greater than or equal to 3 months old, long, untapered) has only 47% probability of success. The probability increases to 84% when the occlusion is tapered. We concluded that in addition to the duration and the length of occlusion, tapered morphology, bridging collaterals, and operator experience can predict successful angioplasty in chronic total coronary occlusion.


Coronary angioplasty performed with gradual and prolonged inflation using a perfusion balloon catheter: procedural success and restenosis rate. The results of routine coronary angioplasty using gradual and prolonged balloon inflation with a perfusion balloon catheter were evaluated. One hundred forty patients were treated with inflation of the balloon to 6 atm over 3 minutes, with a median inflation time of 15 minutes. The procedural success rate (residual stenosis less than or equal to 50%) was 99%. In-hospital major complications occurred in five patients (3.6%), with one patient experiencing a periprocedural infarction, three patients requiring bypass surgery for abrupt closure, and one patient dying after elective bypass surgery following previous successful angioplasty of a culprit lesion. The restenosis rate in the 117 patients with angiographic follow-up (87% of those eligible) was 42%. Thus gradual and prolonged inflation using a perfusion balloon catheter resulted in a high procedural success rate and a restenosis rate similar to that reported in large studies of patients treated with standard angioplasty. These results warrant further study using a prospective randomized trial design.


Endogenous opioid system modulation in anginal pain: demonstration of its central activity. Plasma beta-endorphin levels provide controversial results on the role of endogenous opioid system in modulation of anginal pain. As an alternative, the action of plasmatic luteinizing hormone after administration of naloxone was investigated: naloxone blocks the tonic endogenous opioid system inhibition of gonadotropin release; thus, the level of luteinizing hormone after naloxone administration is an index of central endogenous opioid system activity. Twenty patients with coronary artery disease and positive results of stress tests were selected: 10 had angina (group I) and 10 did not (group II). Ten healthy subjects were also studied as a control group (group III). In all patients basal plasma beta-endorphin levels, basal luteinizing hormone plasma levels (every 15 minutes for 1 hour) and luteinizing hormone plasma levels after administration of 0.1 mg/kg naloxone over 4 minutes (every 15 minutes for 2 hours) were determined. In 15 patients the test was performed after luteinizing hormone releasing hormone was given. The integral concentration time of luteinizing hormone plasma level during baseline (LHiB) and after administration of naloxone (LHiN) or luteinizing hormone releasing hormone (LHiRH), the ratio (LHiN:LHiB and LHiRH:LHiB) and the differences (LHiN-LHiB and LHiRH-LHiB) between the postinfusion period and baseline were calculated. No difference was found in beta-endorphin plasma levels and luteinizing hormone response after luteinizing hormone releasing hormone infusion.(ABSTRACT TRUNCATED AT 250 WORDS)


Effects of sublingually administered nifedipine on left ventricular isovolumic relaxation, diastolic filling, and distensibility in patients with chronic coronary artery disease. The acute effects of nifedipine (20 mg) on left ventricular diastolic function were investigated in 16 patients with chronic coronary artery disease by measuring left ventricular pressure with a manometer-tipped catheter and by measuring volume with cineangiography. Heart rates were maintained by right atrial pacing. Left ventricular peak systolic pressure (-15%; p less than 0.01 vs control) decreased significantly. With afterload reduction, left ventricular ejection fraction (+11%; p less than 0.01) increased. There was no significant change in left ventricular end-diastolic pressure. The diastolic peak filling rate of left ventricular volume significantly increased (+36%; p less than 0.05), whereas the time from end-systole to the peak filling rate remained unchanged. Administration of nifedipine did not improve left ventricular relaxation as assessed by the isovolumic pressure decay. There was also no significant change in the left ventricular diastolic pressure-volume relationship. We conclude that nifedipine improves left ventricular systolic function with afterload reduction but has little or no effect on left ventricular diastolic properties in patients with chronic coronary artery disease.


Mode of QT correction for heart rate: implications for the detection of inhomogeneous repolarization after myocardial infarction. In 22 conscious, chronically instrumented dogs, the relationship between R-R interval and QT interval was better explained by linear regression than by nonlinear regression according to Bazett's formula. The correction formula QTL = QT-0.1*(RR-1000), which is based on the assumption of a linear relationship between QT and R-R interval, was then compared with Bazett's formula regarding its capability to detect inhomogeneous repolarization 5 to 7 days after temporary occlusion of the left anterior descending coronary artery. This comparison was performed only in those dogs exhibiting changes in QRS duration of less than 5 msec in response to myocardial infarction (n = 12). In these animals, myocardial infarction resulted in a significant dispersion of repolarization between the left ventricular normal zone and the infarct zone and a shift to the right of strength-interval curves of the infarct zone with respect to the normal zone, indicating local dispersion of refractoriness. As opposed to QTc (Bazett's formula), QTL was significantly (p = 0.04) prolonged after occlusion. Hence the adequacy of QT correction contributes significantly to the detection of inhomogeneous ventricular recovery after acute myocardial infarction.


Side effects during adenosine thallium imaging with single-port or double-port infusion protocols. The double-port infusion protocol during adenosine thallium imaging involves the use of two infusion systems, one for adenosine and one for thallium. The single-port infusion protocol, on the other hand, uses one infusion system; both adenosine and thallium are injected via a "Y" connection. This study examined the possibility that the single infusion system, by displacing a column of blood filled with adenosine, may be responsible for a greater incidence of side effects. In a parallel study, 140 patients underwent adenosine thallium imaging with the single-port system (group 1) and 140 patients underwent imaging with the double-port system (group 2). Both groups were comparable in age (67 +/- 10 years vs 64 +/- 11 years), gender (men comprised 56% of patients in group 1 and 64% in group 2), resting heart rate, and systolic blood pressure. More patients in group 1 had chest pains (57% vs 44%; p = 0.03), ST-segment depression (25% vs 9%; p = 0.005), nausea (11% vs 4%; p = 0.04), and second- or third-degree atrioventricular block (11% vs 5%; p less than 0.08) than did patients in group 2. The other side effects were similar, and peak heart rate and peak systolic blood pressure were also similar. The thallium images that used single-photon emission computed tomography were abnormal in 61% of patients in group 1 and in 65% of patients in group 2 (p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)


Safety and diagnostic accuracy of adenosine thallium-201 scintigraphy in patients unable to exercise and those with left bundle branch block. Three hundred forty consecutive patients (mean age 69 +/- 9 years) were evaluated with adenosine tomographic thallium-201 scintigraphy for suspected coronary artery disease. Minor side effects occurred in 91% of patients. Out of 28 patients (8%) with potentially serious side effects, 28 had significant atrioventricular (AV) block (second-degree, 24 patients; third-degree, four patients; syncope occurred in two patients). Acute bronchospasm and severe refractory angina pectoris occurred in one patient each. All side effects were transient and without sequelae. One hundred twenty-one patients underwent coronary angiography within 9 days of adenosine thallium imaging. The predictive accuracies of adenosine thallium imaging for identifying and localizing ischemia to a specific coronary distribution were: left anterior descending = 88%, left circumflex = 84%, right coronary = 88%. The predictive accuracy of adenosine thallium imaging in patients with left bundle branch block was 91%, and was higher than the 71% predictive accuracy noted in 39 patients who underwent exercise thallium testing (p = 0.04). It is concluded that adenosine thallium-201 myocardial scintigraphy was (1) highly accurate for the detection and localization of significant coronary artery disease; (2) it was more accurate at detecting ischemia in patients with left bundle branch block than exercise thallium testing, and (3) subjective side effects were common and were of no diagnostic importance; transient AV block occurred occasionally.


Transient ST segment depression during Holter monitoring: how to avoid false positive findings. To increase the specificity of 24-hour Holter monitoring in detecting transient myocardial ischemia, we separated genuine ST deviations from those dependent on artifacts by adding a detailed shape analysis of real-time printouts to the usual criteria of significant ST segment depression. We screened 116 apparently healthy subjects; 31 had to be excluded, because of pathologic findings in preliminary examinations. The remaining 85 (49 women and 36 men; mean age, 43.1 years) underwent Holter monitoring for assessment of the extent, frequency, and duration of episodes of horizontal and descending ST segment depression of at least 0.1 mV that persisted for at least 60 msec after the J point and that were at least 1 minute apart. On the basis of these criteria, six subjects (7.1%) showed 24 episodes of horizontal or descending ST segment depression with a mean of 0.2 mV (range, 0.15 to 0.25 mV), a frequency of four episodes per 24 hours (one to nine), and a duration of 12.2 minutes (range 3-range 41 minutes). Supplementary criteria--e.g., sudden onset of ST segment depression, identical orientation of PQ and ST segments, or simultaneous increase in R and P wave amplitude--made it possible to identify ST changes caused by artifacts in four volunteers. In only two subjects (2.4%) could true silent ischemia not be differentiated from false positive results. Thus consideration of only the extent, frequency, and duration of episodes does not permit a differentiation between true silent ischemia and false positive results. A supplementary shape analysis increases the specificity of ST segment analysis in detecting transient myocardial ischemia during 24-hour Holter monitoring.


Adjuvant metoprolol improves efficacy of class I antiarrhythmic drugs in patients with inducible sustained monomorphic ventricular tachycardia. Inducible ventricular tachycardia frequently persists despite solitary class I antiarrhythmic drug therapy. To determine the effect of metoprolol as adjuvant therapy, 19 patients with clinical ventricular tachycardia with baseline inducible sustained monomorphic ventricular tachycardia and persistently inducible ventricular tachycardia despite class I drugs were evaluated. Eight of 19 patients (42%) became noninducible when metoprolol was added to class I drug therapy. Sixteen of 19 patients (84%) were harder to induce or noninducible on a regimen of adjuvant metoprolol therapy. In evaluating the clinical characteristics of the 19 patients, no significant differences were found between patients who were persistently inducible and those rendered noninducible. In evaluating the electrophysiologic characteristics, the group eventually rendered noninducible had a significantly shorter baseline induced cycle length (259 +/- 27 vs 305 +/- 53 msec). Combination class I drug and metoprolol therapy significantly lengthened the ventricular effective refractory period in both groups compared with baseline. The long-term follow-up was excellent in all patients remaining on metoprolol in the noninducible group. Therefore adjuvant metoprolol therapy creates a significant improvement in a number of patients with persistently inducible ventricular tachycardia despite class I drug therapy.


Role of mapping-guided surgery in patients with recurrent ventricular tachycardia. To assess the value of ventricular tachycardia (VT) surgery 108 patients with recurrent episodes of VT were studied. There were 97 patients with coronary artery disease (group I) and 11 patients without coronary artery disease (group II). All patients in group I underwent subendocardial resection; 12 patients also underwent cryoablation. Cryoablation alone was performed in all patients in group II. During a mean follow-up period of 40 +/- 27 months, 29 patients (30%) in group I and two patients (18%) in group II died (p = 0.33). There were nine patients (9%) in group I and six patients (55%) in group II who had nonfatal recurrences of VT after surgery (p less than 0.01). In group I, there was a higher mortality rate among patients who had VT of posterolateral origin (14 of 31 patients; 45%) compared with 3 of 11 patients (28%) who had VT of anterolateral origin, 1 of 8 patients (12%) who had VT of inferoseptal, and 11 of 39 (29%) patients who had VT of anteroseptal origin. None of the eight patients with two distinct origins of VT died.


A randomized double-blind crossover study comparing the efficacy and tolerability of flecainide and quinidine in the control of patients with symptomatic paroxysmal atrial fibrillation. Patients with paroxysmal atrial fibrillation (PAF) are prone to recurrence. We compared the efficacy and tolerability of flecainide acetate in the control of PAF by means of conventional treatment with quinidine in 19 patients without structural heart disease. A randomized, placebo-controlled, crossover protocol consisting of 8 weeks of treatment with either agent was used. The recurrence of PAF was documented in a symptom diary and confirmed by event ECG recording. Complete control of symptoms was achieved in 4 of 19 and 2 of 11 of patients with flecainide and quinidine, respectively. Both agents prolonged the time to the first recurrence and significantly reduced the total duration of PAF recurrence by 40% and 47%, respectively (p less than 0.05 compared with placebo). Compared with quinidine, flecainide significantly reduced the frequency of recurrence and the rate of PAF during a recurrent episode. However, treatment with flecainide was associated with a higher incidence of symptomatic sinus pauses and visual disturbances compared with a higher incidence of gastrointestinal side effects with quinidine. During a follow-up period of 32 months, satisfactory control was achieved in 74% of patients with the use of these two antiarrhythmic agents.


Contractile, metabolic and arrhythmogenic effects of ionic and nonionic contrast agents in the isolated rat heart. Intracoronary administration of contrast agents may be associated with contractile dysfunction and arrhythmias. To further establish the mechanisms of these alterations, we studied high-energy phosphate metabolism, developed pressure, the occurrence of arrhythmias, and the effects of verapamil during infusion of ionic and nonionic agents in isovolumic, retrogradely perfused rat hearts using 31P nuclear magnetic resonance imaging (NMR). Diatrizoate meglumine (Renografin) infusion reduced developed pressure (DP) to 17.1 +/- 3.4% (p less than 0.001) of the control level, and immediately following termination of the infusion, sudden ventricular tachycardia (VT) was observed in four of six hearts. In the presence of verapamil, meglumine reduced DP to 13 +/- 1.9% of control values and none of these six hearts developed VT. Iopamidol infusion in the presence of verapamil (n = 6) and alone (n = 6) resulted in a decrease in DP to 87% of control value, and no arrhythmias, significant change in high-energy phosphate levels, or changes in pH were observed. These results suggest that contrast-induced contractile depression is not mediated by changes in high-energy phosphate metabolism or pH. Arrhythmias associated with meglumine administration alone and suppressed by verapamil are probably related to calcium loading.


Influence of mitral valve morphology on mitral balloon commissurotomy: immediate and six-month results from the NHLBI Balloon Valvuloplasty Registry. Echocardiographic data were analyzed in 555 patients undergoing mitral balloon commissurotomy (MBC). Patients were enrolled in the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry from 24 centers. There were 456 women and 99 men with a mean age of 54 years. Before MBC the two-dimensional echocardiographic variables of mitral valve thickness, mobility, calcification, and subvalvular disease were evaluated and assigned scores of 1 to 4. The mitral valve morphology score was related to mitral valve area (MVA) measured after MBC by cardiac catheterization. The leaflet mobility score was related to the immediate post-MBC MVA: 2.2 +/- 0.8 cm2 for grade 1, 1.9 +/- 0.7 cm2 for grade 2, 1.7 +/- 0.7 cm2 for grade 3, and 1.9 +/- 0.9 cm2 for grade 4 (p less than 0.001). Results of the MVA after MBC showed a similar relationship for each echocardiographic variable. The total morphology score (sum of the four variables) showed a weak relationship to MVA immediately after MBC (r = 0.24), which was persistent at 6 months after MBC (r = -0.25). Multiple regression analysis showed that the MVA after MBC is predicted by pre-MBC MVA (p less than 0.001), left atrial size (p = 0.01), balloon diameter (p = 0.02), cardiac output (p = 0.004), and leaflet mobility (p = 0.01). The R2 of the model was 0.31 (p less than 0.001). Total morphology score, leaflet thickness, calcification, and subvalvular disease were not important univariate or multivariate predictors of the results of MBC.(ABSTRACT TRUNCATED AT 250 WORDS)


Systolic anterior motion of the chordal apparatus after mitral ring insertion. To describe the Doppler and two-dimensional echocardiographic characteristics of systolic anterior motion of the chordal apparatus after mitral annuloplasty, 24 consecutive patients (19 men and 5 women; mean age, 55 years) were studied with the use of serial Doppler and two-dimensional echocardiography, which included preoperative transthoracic, intraoperative epicardial, and postoperative transthoracic examinations at 1 week after annuloplasty and every 3 months thereafter for up to 12 months. Systolic anterior leaflet motion of the mitral valve was not seen in this series; however, chordal systolic anterior motion was seen in three patients during surgery and in one additional patient at the time of the 1-week transthoracic examination. During subsequent studies at 3-month intervals, chordal systolic anterior motion was not present. The left ventricular outflow tract velocities were normal in all patients with and without chordal systolic anterior motion. In conclusion, chordal systolic anterior motion should be differentiated from leaflet systolic anterior motion after mitral annuloplasty because the former is a transient, benign, and relatively common finding.


Mobile strands are frequently attached to the St. Jude Medical mitral valve prosthesis as assessed by two-dimensional transesophageal echocardiography. Two-dimensional transesophageal echocardiographic findings are reported in 13 patients with structurally and functionally normal St. Jude Medical bileaflet mitral valve prostheses. Multiple mobile linear echogenic densities attached to the pivot of the prosthesis were present in 9 of 13 patients. These densities may represent fibrin strands. These mobile strands alternatively resolve and reform over a period of 5 to 14 months after mitral valve replacement. No adverse clinical events were attributable to these prosthetic mitral valve strands. We conclude that mobile stands are frequently attached to the structurally and functionally normal St. Jude Medical mitral valve prosthesis. The clinical significance of these prosthetic mitral valve strands requires clarification.


Comparison of cardiac dimensions by transesophageal and transthoracic echocardiography. Transesophageal echocardiography (TEE) has advanced rapidly as a valuable cardiovascular diagnostic technique. As the use of TEE increases, so does the importance of well-defined normal cardiac measurements. Presently, few data exist on the accuracy of M-mode TEE-derived measurements. Therefore in 81 adult patients, TEE-derived M-mode measurements were compared with analogous measurements that were made by standard M-mode transthoracic echocardiography (TTE). The TTE and TEE measurements did not differ in aortic root diameter, end-diastolic left ventricular diameter, end-diastolic septal wall versus anterior wall thickness, or end-diastolic posterior wall versus inferior wall thickness. These TEE measurements were within 95% confidence limits of TTE measurements. TEE-derived left atrial diameter (3.5 +/- 0.8 cm) was less than that derived by TTE (3.8 +/- 0.8 cm; p less than 0.001) and fell outside of the 95% confidence interval. TTE left atrial size could be estimated as follows: TTE-derived left atrial diameter = TEE-derived left atrial diameter x 0.6 + 1.5 cm. In conclusion, M-mode measurements of aortic root diameter, left ventricular diameter, and wall thicknesses as derived by TTE and TEE are comparable. TEE-derived left atrial diameter may be used to estimate the left atrial TTE measurement. TEE-derived M-mode measurements are likely to be most useful when results of TTE are technically inadequate.


The influence of obesity on left ventricular filling and systolic function. Little information on the possible influence of obesity on diastolic function is available. Thus we studied 24 asymptomatic obese volunteers (greater than 120% ideal body weight; mean 153 +/- 30%), aged 34 +/- 11 years. Each obese subject was matched for age, height, and sex, with a healthy normal-weight control subject. Isovolumic relaxation time (IVRT) and diastolic filling indexes were determined by pulsed Doppler echocardiography. The IVRT was significantly prolonged in the obese group (84 +/- 17 msec) as compared with the control group (57 +/- 13 msec; p less than 0.0002). Multiple regression analysis showed that percentage of ideal body weight was the most important predictor of peak early filling velocity (r = 0.59, p less than 0.005) and mean deceleration rate of early filling (r = 0.61, p less than 0.005) in the obese group. However, age as compared with percentage of ideal body weight was a more important determinant of the relative distribution of early and atrial filling, such as peak early-to-atrial filling velocity ratio (r = -0.75, p less than 0.0001). Ejection fraction, heart rate, and blood pressure did not differ between the obese and control groups. In conclusion, obesity is associated with preclinical abnormalities of IVRT, which may reflect impaired relaxation. The IVRT may be useful in the early detection of left ventricular dysfunction in obesity. Last, studies comparing Doppler indexes of diastolic filling among groups must control for potential differences in percentage of ideal body weight.


Ventilatory mechanisms of exercise intolerance in chronic heart failure. Mechanisms that have been suggested to underlie the abnormal ventilatory response to exercise in patients with chronic congestive heart failure (CHF) include high pulmonary pressures, ventilation-perfusion mismatching, early metabolic acidosis, and abnormal respiratory control. To evaluate the role that ventilation and gas exchange play in limiting exercise capacity in patients with CHF, data from 33 patients with CHF and 34 normal subjects of similar age who underwent maximal exercise testing were analyzed. Maximal oxygen uptake was higher among normal subjects (31.7 +/- 6 ml/kg/min) than among patients with CHF (17.7 +/- 4 ml/kg/min; p less than 0.001). The ventilatory equivalent for oxygen, expressed as a percentage of maximal oxygen uptake, was 25% to 35% higher among patients with CHF compared with normal subjects throughout exercise (p less than 0.01). A steeper component effect of ventilation on maximal oxygen uptake was observed among normal subjects compared with patients with CHF, which suggests that a significant portion of ventilation in CHF is wasted. Maximal oxygen uptake was inversely related to the ratio of maximal estimated ventilatory dead space to maximal tidal volume (VD/VT) in both groups (r = -0.73, p less than 0.001). Any given oxygen uptake at high levels of exercise among patients with CHF was accompanied by a higher VD/VT, lower tidal volume, and higher respiratory rate compared with normal subjects (p less than 0.01). Relative hyperventilation in patients with CHF started at the beginning of exercise and was observed both below and above the ventilatory threshold, which suggests that the excess ventilation was not directly related to earlier than normal metabolic acidosis. Thus abnormal ventilatory mechanisms contribute to exercise intolerance in CHF, and excess ventilation is associated with both a higher physiologic dead space and an abnormal breathing pattern. The high dead space is most likely due to ventilation-perfusion mismatching in the lungs, which is related to poor cardiac output, and the abnormal breathing pattern appears to be an effort to reduce the elevated work of breathing that is caused by high pulmonary pressures and poor lung compliance.


A comparison of the acute hypotensive effects of two different doses of nifedipine. To determine whether a dose of 5 mg of nifedipine would be useful in the treatment of hypertensive emergencies, we compared the acute hypotensive effects of two different doses of nifedipine, 5 mg and 10 mg, in patients with severe hypertension. In this prospective, randomized, double-blind study, 30 consecutive black patients with diastolic blood pressure that was equal to or greater than 115 mm Hg received either a 5 mg or 10 mg nifedipine capsule and a placebo capsule, which matched that of the alternative strength. Patients were asked to bite the capsules and swallow the contents. Blood pressure response over 4 hours and adverse effects were monitored. Mean systolic blood pressure was reduced from 191.7 mm Hg (95% confidence interval 170.8 to 212.7 mm Hg) to 157.9 mm Hg (137.0 to 178.9 mm Hg) and 206.1 mm Hg (185.1 to 227.0 mm Hg) to 153.7 mm Hg (132.8 to 174.7 mm Hg) in patients who were given 5 mg and 10 mg doses of nifedipine, respectively. Mean diastolic blood pressure in the group of patients that received 5 mg doses of nifedipine decreased from 128.2 mm Hg (115.6 to 140.7 mm Hg) to 105.2 mm Hg (92.7 to 117.7 mm Hg); the corresponding values in the group that received 10 mg doses of nifedipine were 129.9 mm Hg (117.4 to 142.5 mm Hg) and 97.5 mm Hg (85.0 to 110.1 mm Hg), respectively. The minimum mean systolic blood pressures occurred 20 and 25 minutes after administration of the 5 mg and 10 mg capsules, respectively; the minimum diastolic blood pressures were reached after 20 and 30 minutes, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)


Regional blood flow in human congestive heart failure. Despite the total-body consequences of congestive heart failure, little information is available on the distribution of cardiac output and regional-organ hemodynamics in this condition in humans. Technical and methodologic limitations probably account for the paucity of data in this area. Available data indicate that blood flow to the regions or organs studied, namely, the kidneys, hepatosplanchnic region, and upper limbs, decreases in proportion to the reduction in cardiac output. However, renal blood flow appears to be protected in human heart failure by a form of "autoregulation" during marked depression of cardiac output (less than 2.0 L/min/m2). Results of preliminary studies suggest that the regulation of regional-organ hemodynamics is disturbed in this human condition. Cardioactive drugs profoundly affect regional-organ hemodynamics independent of changes in central hemodynamics and cardiac output. The determination of regional blood flow responses in human heart failure will become more important as we expand our knowledge base of the pathophysiology of heart failure, learn more about local vascular control mechanisms, and pursue the potential therapeutic objective of selectively augmenting regional-organ hemodynamics and function.


Arterial occlusive disease in occult cancer. Thromboembolism frequently complicates advanced cancer. The incidence of TE as one of the initial manifestations of occult cancer and the diagnostic value of TE as a signal of a possible unrecognized tumor were the subjects of recent studies. TE may precede the diagnosis of cancer by several months or years. The polymorphism of manifestations of paraneoplastic TE has been described previously. An accelerated course of intermittent claudication and of ischemic heart disease has been described in patients with cancer and probably represents additional variants of Trousseau's syndrome. Recently, clues for the presence of occult neoplasms in patients with TE have been proposed. Their value in the stratification of patients needs to be established in prospective studies. That cancer may be responsible for a precipitated course of coronary or peripheral arterial disease raises the question of whether work-up is recommended to uncover a silent malignancy in a patient who has been referred for treatment of these severe ischemic syndromes.


The electrocardiographic, clinical, and electrophysiologic spectrum of idiopathic monomorphic ventricular tachycardia. Clinical, ECG, and electrophysiologic data from 47 patients who had episodes of sustained or nonsustained monomorphic VT with no evidence of structural heart disease were reviewed. According to the QRS configuration during tachycardia, four groups were distinguished. Nine patients had a right bundle branch block configuration and superior frontal plane QRS axis (group 1). Nine patients had a right bundle branch block configuration but an intermediate or right QRS axis (group 2). Group 3 consisted of five patients with a left bundle branch block configuration and a left axis deviation, and in group 4 there were 24 patients who had a left bundle branch block configuration with an intermediate or right frontal axis. Patients in group 1 had dizziness during tachycardia less frequently, but they needed cardioversion to terminate their arrhythmias more often. They experienced tachycardia during exercise less often, and tachycardia was not initiated during exercise testing. They had fewer ventricular premature beats according to the Holter recording. During the electrophysiologic study, VT was induced and terminated by pacing more often in this group. Patients with idiopathic VT with a right bundle branch block configuration and a superior axis seem to be a unique group of patients with idiopathic VT, and reentry seems to be the most likely arrhythmia mechanism in this group. The other ECG configurations share the same clinical and electrophysiologic characteristics, which suggest that the underlying arrhythmia mechanism is the same.


The use of antibodies in clinical cardiology. Monoclonal antibody technology has resulted in an entirely new class of agents, which have been applied to a variety of problems in cardiology and which hold great promise for future diagnostic, as well as therapeutic, applications. The four antibodies, which have been most widely used in clinical cardiology, are Digibind, OKT3, Myoscint, and 7E3. Each demonstrates the unique potential for the use of antibodies in clinical cardiology.


Efficacy of lipid profiles in prediction of coronary disease. National guidelines in the United States and Europe have stimulated interest in controlling blood lipid levels to prevent CHD. In this review, the efficiency of lipid profiles in predicting CHD has been examined, and total cholesterol, HDL and LDL cholesterol, and triglyceride values have been compared on the basis of 12 to 14 years of surveillance in the Framingham Study. The average value of total cholesterol and LDL cholesterol in patients who had coronary disease was at or below values that are considered dangerous, which indicates the need for more specific and sensitive lipid profiles. Measurement of LDL cholesterol levels predicted CHD only marginally better than measurement of serum total cholesterol. Measurement of triglyceride levels was the weakest predictor. The total cholesterol to HDL cholesterol ratio was the most efficient predictor both in those with apparently safe and those with abnormal cholesterol values. Measurement of HDL cholesterol was the best single lipid predictor and use of this measurement avoids needlessly alarming or falsely reassuring persons at risk for CHD who have high total cholesterol values. Since the risk associated with any serum cholesterol value varies over a 10-fold range depending on coexistent cardiovascular risk factors, these lipid factors must be taken into account in judging the hazards and efficacy of treatment needed. Evidence is available that controlling elevated cholesterol by diet and administration of pharmaceutical agents can reduce the rate of coronary events, slow progression of angiographically visualized lesions, and regress xanthomata.(ABSTRACT TRUNCATED AT 250 WORDS)


Serum lactate dehydrogenase in childhood neuroblastoma. A Pediatric Oncology Group recursive partitioning study. On the basis of an extensive recursive partitioning analysis of 668 patients with newly diagnosed neuroblastoma registered on Pediatric Oncology Group (POG) studies between October 1981 and May 1987, four major subsets of patients were created. Important prognostic factors included the patient's stage of disease, age, and level of serum lactate dehydrogenase (LDH). After adjusting for these factors, no other clinical prognostic factors were significant. The implications for protocol design are that (a) fine tuning of current therapy should be sought for the two favorable disease patient subsets, while (b) novel aggressive therapies are needed for the two unfavorable disease patient subsets where the overwhelming majority are dying. This article may serve as a model for others investigating prognostic factors. The data were divided into two subsets: one was used for an exploratory analysis; the other was used to confirm the exploratory findings. Despite spite the large number of statistical tests performed, the likelihood that the findings can be attributed to chance can be dismissed as virtually zero.


Total nodal radiation in progressive sarcoidosis. Case report. The subject of this article is a patient with sarcoidosis with neurological involvement, who failed to respond to high dose steroid therapy and cyclophosphamide. Low doses (20 Gy) of total nodal and craniospinal irradiation resulted in an excellent response, the patient being alive and in good health 3 years after irradiation without any further steroid therapy.


Etoposide plus carboplatin admixture. Phase I study of five- or seven-day continuous infusion. Thirty-five patients were entered in a Phase I trial of an admixture infusion of etoposide (VP-16) and carboplatin (CBDCA) administered continuously for 5 or 7 days. Because of the compatibility and solubility of the two agents, the treatment program could be administered on an outpatient basis. The dose rate of VP-16 was fixed at 30 mg/m2/day (total dose 150 mg/m2 for 5 days or 210 mg/m2 for seven days) for each cycle. Carboplatin was evaluated at three dose rates: 50, 60, and 75 mg/m2/day on the 5-day infusion and 40, 50, and 60 mg/m2/day on the 7-day infusion with cycles repeated at 28 to 42 days. The dose limiting toxicity was hematologic and followed a pattern typical for carboplatin, that is, delayed neutropenia and/or thrombocytopenia with a protracted leukocyte recovery. Renal toxicity was observed in three patients. The optimum total dose for the infusional carboplatin component was 300 mg/m2 (5-day) and 420 mg/m2 (7-day). The total etoposide dose was 150 mg/M2 and 210 mg/M2, which did not appear to contribute to the hematologic toxicity. Delivery of the admixture of VP-16 and CBDCA was feasible, although cumbersome, as a result of the portable delivery system. Extending the duration of infusion increases the total cumulative dose of carboplatin and etoposide that can be administered without increasing adverse effects.


Deferoxamine, cyclophosphamide, etoposide, carboplatin, and thiotepa (D-CECaT): a new cytoreductive chelation-chemotherapy regimen in patients with advanced neuroblastoma. Thirteen patients with Stage III (3 patients) or Stage IV (10 patients) neuroblastoma were treated with a new iron chelation-cytotoxic therapy regimen. Deferoxamine given for five consecutive days followed by 3 days of cyclophosphamide, etoposide, carboplatin, and thiotepa (D-CECaT) caused moderate to severe myelotoxicity. In 39 courses there were four episodes of sepsis; platelet and packed red blood cell transfusions were required in 72% and 82% of courses, respectively. Mild nausea and vomiting occurred in 52% of courses. Objective responses after two courses were observed in 12 of 13 patients. Three of four partial responses were achieved in previously treated relapsed patients, and seven of eight complete responses (four of which were surgically documented) were achieved in previously untreated patients. This cytoreduction regimen appears to be an improvement over other initial induction regimens and may be worth testing in larger populations.


Intraoperative radiation therapy of extrahepatic biliary carcinoma: a report of RTOG-8506. Twenty-three patients with unresected, resected but residual, or locally recurrent biliary duct cancer were entered on a Radiation Therapy Oncology Group (RTOG) Phase I-II study. Of 16 patients who were properly entered and eligible for study, eight patients (50%) completed protocol treatment including intraoperative radiation therapy (IORT). Minor acute complications from therapy were common. There was no early grade 3 or 4 toxicity. Major long-term toxicity (grade 4) was noted in one patient who suffered a perforated viscous related to salvage radiation therapy for a scar recurrence and died of infection 1 month after retreatment. With a median follow up of 10.5 months, two of the eight patients who received IORT are alive. Of the six patients who died, one had persistent disease, one had the tumor recur in the surgical wound and subsequently died of complications related to retreatment with high dose radiation, and one died of intercurrent disease. In addition, two patients died with liver metastasis, and one died with intraabdominal disease outside of the IORT volume. Bulk of disease may be an important determinant of outcome.


A phase I-II study of recombinant intrapleural alpha interferon in malignant pleural effusions. Malignant pleural effusion is a common and significant source of morbidity for many patients with cancer. In an attempt to control this condition without using chest tube drainage, we administered recombinant interferon alpha-2b (INTRON, Schering-Plough, Kenilworth, NJ) intrapleurally via catheter after routine thoracentesis. Twenty-two installations of interferon were administered to 15 patients in incremental dosages of 3-50 x 10(6) U/m2. Of 20 evaluable treatments, six (30%) achieved effusion stabilization; there were no complete or partial responses. Only one of nine treatments at a dosage less than 20 x 10(6) units/m2 resulted in symptoms, while four of 11 treatments at the higher dosage were associated with transient fever, chills, and chest pain. Interferon demonstrated no major activity in this heavily treated patient population with advanced malignancy.


Salvage carboplatin therapy for advanced ovarian cancer after first-line treatment with cisplatin. From April 1989 to August 1990, 17 patients with Stage 3 or 4 epithelial ovarian cancer (EOC) were treated with intravenous carboplatin (160-400 mg/m2) for refractory or recurrent disease after first-line treatment with cisplatin-based combination chemotherapy. Of fifteen patients evaluable for activity, two complete responses and two partial responses were seen, for a response rate of 27%. The duration of response was 4.5, 5, 8, and 9.2 months, respectively, and responders survived longer than nonresponders. Of the nine evaluable patients receiving carboplatin as the first salvage treatment, four responses were seen. Dose selection for the first cycle of carboplatin was based on previous treatment, and adjustments were made on the basis of myelosuppression. In general, treatment was well tolerated--severe myelosuppression occurred after 6 of 73 cycles. This review confirms previous reports of anti-tumor activity of carboplatin in patients with refractory or recurrent advanced EOC who respond to first-line treatment with cisplatin. Further evaluation may help define the toxicity and efficacy of salvage treatment with carboplatin compared to cisplatin in patients who recur after a prolonged disease-free interval after first-line cisplatin-based therapy.


Effect of calcium replacement on the hemodynamic changes associated with high dose interleukin-2 therapy. Administration of high-dose IL-2 results in hemodynamic changes that are similar to those seen in septic shock. These include a decrease in systemic vascular resistance (SVR) with a resultant drop in mean arterial pressure (MAP). Hypocalcemia is seen in septic shock and with IL-2 administration. Calcium replacement in septic shock has been reported to result in hemodynamic improvement; we therefore administered calcium to patients receiving high dose IL-2 to correct ionized hypocalcemia. Five consecutive patients underwent invasive hemodynamic monitoring before and during IL-2 administration. Calcium chloride was administered to correct ionized hypocalcemia, and hemodynamic parameters were monitored before and after calcium administration. Ionized hypocalcemia was associated with an elevation in parathyroid hormone levels. There was no toxicity related to the administration of calcium. An improvement in the MAP and SVR was seen early and late (after a dose of IL-2 was held) in the IL-2 treatment cycle; there were minimal effects at other points. Because of the potential hemodynamic benefit of calcium replacement, we recommend that ionized hypocalcemia be corrected in patients receiving high-dose IL-2.


Intravenous and oral magnesium supplementations in the prophylaxis of cisplatin-induced hypomagnesemia. Results of a controlled trial. The effects of oral and intravenous magnesium supplementation on cisplatin (CDDP)-induced hypomagnesemia were investigated in 41 patients treated with 100 mg/m2 CDDP. Patients were randomly allocated to receive no magnesium supplementation, intravenous magnesium supplementation (magnesium sulphate, 3 g before each CDDD administration) or oral magnesium supplementation (magnesium pidolate, 2 g orally every 8 hours on days 2 to 21 of each CDDP course) during the first 4 courses of CDDP treatment. Patients in both supplementation arms showed significantly higher magnesium levels than control patients from the second course on (oral magnesium arm) or from the third course on (intravenous magnesium arm). Three of the 9 patients (33%) in the intravenous magnesium arm and 4 of the 9 (44%) in the oral magnesium arm developed hypomagnesemia after the fourth course of CDDP, compared with 9 of the 10 (90%) unsupplemented patients. There were no magnesium-related side effects in patients on intravenous magnesium supplementation. Two patients treated with oral magnesium developed mild gastrointestinal symptoms (emesis and diarrhea), probably from magnesium therapy. Our study showed that both intravenous and oral magnesium supplementations appear to be safe and efficacious in the prevention of CDDP-induced hypomagnesemia. Since patients were not completely protected, and since the analysis was limited to the first four courses of chemotherapy, additional studies are needed to determine the best schedule of magnesium supplementation, especially in patients who receive more than four courses of CDDP chemotherapy.


Superior vena cava obstruction in a patient with chronic lymphocytic leukemia and lung cancer. A patient with cervical lymphadenopathy secondary to chronic lymphocytic leukemia (CLL) developed acute superior vena cava (SVC) obstruction. Poor response to chemotherapy, a history of smoking, and lobar atelectasis suggested a different diagnosis. Bronchoscopy established the presence of a bronchogenic adenocarcinoma of the right lung as the etiology of the obstruction. Based on our experience and a review of the literature, we recommend that if a patient with CLL or a diffuse well-differentiated lymphocytic lymphoma presents with or develops SVC obstruction, additional invasive diagnostic tests must be initiated to exclude the possibility of a coexistent second malignancy or a transformation to a higher grade lymphoma. Other features warranting a search for another diagnosis are lack of the expected response to glucocorticoids, chemotherapy, or radiation therapy.


The increasing recognition of adenosquamous lung carcinoma (1977-1986). A retrospective analysis of the data in the tumor registry on all 103 patients with adenosquamous lung carcinoma diagnosed and treated at our center between 1977 and 1986 was performed. The history of tobacco use was available for 100 patients (72 men and 28 women). Ninety-four percent of the patients (100% of men and 79% of women) were smokers, suggesting that adenosquamous carcinoma may be a Kreyberg I type of lung carcinoma. The gender, race, and age distributions in adenosquamous carcinoma were similar to other histologic subtypes of lung carcinoma. Patients less than 45 years old constituted 10%; 45-54 years old, 24%; 55-64 years old, 34%; 65-74 years old, 25%; and greater than 75 years, 7%. In the 95 patients whose stage at the time of diagnosis was known, 11% had local stage; 28%, regional; and 61%, distant stage. The 1-, 2- and 5-year survival of the 103 patients were 27%, 18%, and 8%, respectively. Survival was related to stage. Local stage had the best survival, and greater than 50% of patients were alive at 4 years. Regional stage had an intermediate median survival of 10 months but no survivors at 5 years. Distant stage had the worst median survival (5 months), and one patient (2%) was alive at 3 years. There was a significant increase (two- to three-fold) in the frequency of adenosquamous carcinoma over the 10-year study period, 1977-1986.


Finger injuries involving stationary exercise bicycles. Injuries to children related to exercise bicycles can result in significant morbidity, but are almost entirely preventable. To forestall these injuries, manufacturers should continue to focus their attention on improved design and developing safer equipment. In addition, pediatricians and other primary care providers need to play a role in educating parents and the community about the possible hazards that exercise bicycles present to young children.


Immunization practices of Washington State pediatricians--1989. Administration of immunizations has become complicated by issues about consent, cost, and liability. To determine if these issues have changed the immunization practices of pediatricians, we surveyed pediatricians in private practice in Washington State. The survey results show that about one half of vaccines administered in pediatricians' offices are provided by the Washington State Health Department. The mean charge for administration of each parenteral vaccine was $7.02. Respondents strongly agreed that they would administer vaccine supplied by the Washington State Health Department if it was available. They also agreed that they referred patients to Health Department clinics for vaccination because of inability to pay and not because of concern about liability.


Acute-phase reactants and acute bacterial otitis media. To determine if the erythrocyte sedimentation rate and C-reactive protein level are elevated in uncomplicated acute bacterial otitis media. Investigator-blinded, antibiotic efficacy trial. The emergency department of an urban regional children's hospital with 24,000 annual visits. Thirty-one children with symptoms of acute bacterial otitis media of 7 days' duration or less. Volunteer sample. Tympanocentesis, oral antibiotics for 10 days, and three follow-up visits in the next 30 days. The erythrocyte sedimentation rate and C-reactive protein level were obtained at time of entry into the antibiotic study. Seventeen patients (55%; 95% confidence interval, 37% to 72%) had either an erythrocyte sedimentation rate above 20 mm/h or a C-reactive protein level above 8 mg/L. Eleven patients (35%) had a recurrent episode of acute bacterial otitis media during the follow-up period. The relative risk of recurrence of otitis media given an elevated erythrocyte sedimentation rate or C-reactive protein level was 8.24 (95% confidence interval, 1.20 to 56.74; Fisher's Exact Test; P = .007). Clinicians who use elevated acute-phase reactants as possible indicators of invasive bacterial infections should be aware that an elevated erythrocyte sedimentation rate or C-reactive protein level is also consistent with acute bacterial otitis media. An elevated erythrocyte sedimentation rate or C-reactive protein level also appears to be associated with an increased risk of recurrence of acute bacterial otitis media. If these findings can be confirmed in a larger study, the erythrocyte sedimentation rate or C-reactive protein level could be used to assess the risk of recurrent otitis media.


Severe laryngotracheobronchitis complicating measles. To determine the incidence of severe measles-related laryngotracheobronchitis in patients hospitalized during a recent measles epidemic and to evaluate factors associated with severity of airway injury and its management. Clinical description of patient series. Children's hospital and county general hospital, Houston, Tex. One hundred twenty-four children (aged 1 month to 19 years) admitted with a diagnosis of measles. None. Twenty-seven patients had significant laryngotracheobronchitis, including 10 who had not received appropriate immunization. Six patients required endotracheal intubation for relief of upper airway obstruction. The median age of patients requiring intubation was 12 months (range, 4 to 24 months). Two patients died of complications of superinfection. Two patients survived but required prolonged intubation. Two patients underwent early diagnostic laryngoscopy and bronchoscopy and required shorter artificial airway maintenance. Severe laryngotracheobronchitis frequently occurs in patients younger than 2 years hospitalized with measles and may be related to bacterial or viral super-infection. Early diagnostic laryngoscopy and bronchoscopy for injury assessment and possible endotracheal tube exchange are recommended and, in some severe cases, tracheostomy should be considered to shorten artificial airway maintenance and decrease the incidence of airway complications.


Care of the pediatric organ donor.

Care of the pediatric organ donor. Solid organ transplantation has become an accepted therapeutic option in pediatrics. Many previously fatal diseases have become current indications for organ transplantation. A major limitation to the growth of this therapeutic option is the availability of suitable organs. With organ supply falling far short of demand, recruitment of donors has been stressed. In addition to recruiting donors, physicians are responsible for maintaining optimal organ function in a beating heart organ donor to ensure that all organs that could potentially be harvested are in a condition suitable for transplant. Current information demonstrates numerous physiologic changes resulting from cerebral death. Therapeutic interventions must focus on maintenance of function in all potentially transplantable organs, including kidneys, heart, lungs, liver, and pancreas. Physicians should recognize the interventions that might compromise the use of an organ in transplant. Criteria for organ use are constantly changing, and the implications of different therapeutic interventions must still be evaluated.


The role of assisted ventilation in survival after respiratory failure in children with AIDS. To determine the role of assisted ventilation in children with the acquired immunodeficiency syndrome and acute respiratory failure, and to identify any measurement or variable that predicted survival. Retrospective study. Kings County (New York) Hospital Center, a tertiary-level inner-city municipal hospital. Twenty-three children with acquired immunodeficiency syndrome who were endotracheally intubated and mechanically ventilated because of acute respiratory failure. There were 24 episodes of acute respiratory failure, as one patient survived a first episode and died during the second episode 2 years later. We failed to identify any measurement or variable that predicted survival. During 12 episodes (50%), the patients survived and were weaned from the ventilator. Our findings indicate that a decision to avoid intubation and assisted ventilation in a child with acquired immunodeficiency syndrome and acute respiratory failure should not be made based merely on the presumption of a lethal outcome.


Experience with flexible fiberoptic bronchoscopy with bronchoalveolar lavage as a diagnostic tool in children with AIDS. To report our experience with flexible fiberoptic bronchoscopy with bronchoalveolar lavage in children with the acquired immunodeficiency syndrome and acute lower respiratory tract disease. Retrospective study. Children's Medical Center of Brooklyn, NY, a tertiary-level inner-city hospital. Eighty-five children with acquired immunodeficiency syndrome and acute lower respiratory tract disease. One hundred five flexible fiberoptic bronchoscopies with bronchoalveolar lavages. Infective agents were recovered in 88 procedures (84%). Potentially pathogenic bacteria were identified in 56 (56.6%) of 99 procedures. Viruses were found in 28 (29%) of 96 lavages, and fungi in 37 (41.6%) of 89 specimens. Pneumocystis carinii was identified in 22 (22.2%) of 99 specimens. Mycobacteria were isolated from 14 (14%) of 100 specimens. A serious complication occurred in only one procedure (0.95%). Flexible fiberoptic bronchoscopy with bronchoalveolar lavage is a safe and effective diagnostic procedure that identified infective agents in 80% of children with acquired immunodeficiency syndrome and concomitant acute lower respiratory tract disease.


Superior vena cava syndrome associated with lymphoma. To evaluate the workup and treatment of children with lymphoma and superior vena cava syndrome. A retrospective survey. State hospital serving as a secondary and tertiary referral center for pediatric oncology and pediatric cardiac surgery. Eleven children aged 11 months to 12 years diagnosed as having lymphoma or T-cell acute lymphoblastic leukemia who presented with superior vena cava syndrome during an 11-year period. Lymph node biopsy (two patients), thoracenthesis (five patients), bone marrow aspiration (two patients), and thoracenthesis in addition to bone marrow aspiration (two patients). All aspirates were evaluated with immunohistochemical studies. Chemotherapy was the only management intervention. T-cell lymphoma or leukemia accounted for nine cases and Hodgkin's disease for two cases. Respiratory symptoms occurred in 10 patients, including tracheal compression in six patients (compression was life-threatening in one patient). Diagnosis of superior vena cava syndrome was achieved in eight patients using surface-marker analysis of aspirates. The syndrome disappeared within 2 to 10 days. Seven of nine children whose conditions were diagnosed more than 1 year before this writing were alive and free of disease after mean follow-up of 37 months. (1) A specific diagnosis can be achieved in most children with superior vena cava syndrome and lymphoma; (2) Thoracic computed tomographic scans are essential, identifying minute pleural effusions that can aid diagnosis; (3) Anesthetic hazard is related only to severe tracheal compression; (4) Chemotherapy achieves excellent symptomatic relief; and (5) Long-term survival, without disease, is achievable.


Home visits by pediatric residents. A valuable educational tool. To establish how many pediatric residency programs offer home visits, to assess the feasibility of making home visits as part of pediatric training, and to determine whether residents perceive home visits as worthwhile learning experiences. A questionnaire was mailed to all medical school pediatric departments in the United States and Puerto Rico to determine the prevalence of home visits during residency training. To study the feasibility of residents making home visits, a pilot program was instituted. Fourteen pediatric residents participated in the study. Each resident visited a house, trailer, apartment, or shelter for the homeless that was within a 20-minute radius from the medical center. To determine the educational value of home visits, each resident wrote a one-page report immediately on his or her return to the hospital. After about 6 months, all participating residents completed a questionnaire retrospectively evaluating their home visits. Interns who were neither on-call nor postcall the day of the visits were invited to participate. Patients were selected because they were homebound (eg, ventilator-dependent), had missed follow-up appointments, or had transportation difficulties. Thirteen percent of the pediatric residency programs surveyed currently include home visits. In all 14 of the pilot visits, the home was located without difficulty and the patient was at home. In each case, the family welcomed the visit. All the pediatric residents believed that the home visit was a worthwhile learning experience. Although very few programs (13%) currently offer home visits as part of pediatric residency training, such visits are feasible within a large urban area. Residents are enthusiastic about seeing how and where their patients live, and consider home visits a worthwhile learning experience.


Anaerobic endurance and peak muscle power in children with spastic cerebral palsy. The aim of this study was to provide information on anaerobic muscle endurance (mean power) and peak muscle power in children with spastic cerebral palsy. We measured peak power and mean power of the upper and lower limbs in 29 boys and 20 girls, aged from 6 to 14 years, by means of the Wingate Anaerobic Test. In addition, the physical components (physical capacity, upper limb, and lower limb) of a system used for evaluating function in the physically disabled were assessed. Of the 49 subjects, 46 and 37 successfully completed the arm and leg Wingate Anaerobic Test, respectively. Compared with norms for age and gender (healthy, nonathletic children), peak and mean power in the patients, even when corrected for body weight, were distinctly subnormal. The performance of subjects with quadriplegia was 3 to 4 SDs below the mean for controls. Twenty-five of diplegic and hemiplegic subjects had values below 2 SDs. When the data were analyzed according to the severity of the cerebral palsy, with the use of the physical capacity, upper limb, and lower limb score, those children with moderate to severe cerebral palsy had values for mean and peak power of the arm and leg 3 to 4 SDs below the normal mean. Values for children with only mild cerebral palsy also fell below the mean, but the data were more scattered, especially for the leg. The lower muscle performance may reflect both quantitative and qualitative differences in the upper- and lower-limb muscles, due to altered innervation and, in the more severely affected children, disuse.


Calories count. Improved weight gain with dietary intervention in congenital heart disease. We assessed the nutritional status of patients with congenital heart disease (CHD) to evaluate the role of dietary intake in impaired weight for patient length. Underweight patients with CHD underwent nutritional counseling to evaluate the role of this intervention in improvement of weight for length. We prospectively evaluated a clinical protocol for nutritional assessment and counseling in patients with CHD. Eligible patients were enrolled from a cardiology clinic during a 13-month period. Initial anthropometric measurements and measurements of dietary intake of underweight and normal-weight patients were compared. Initial and follow-up measurements of underweight patients who received nutritional counseling were compared. Nineteen underweight patients with CHD and 16 normal-weight patients with CHD, aged 1 month to 2 years, were studied. Exclusion criteria included noncardiac factors that could affect growth (eg, low birth weight, Down syndrome, gastrointestinal deficit, and any severe abnormality of the central nervous system). Seventeen of the 19 underweight patients underwent nutritional counseling in the presence of a parent every 2 months for 6 months. Caloric and protein intakes were maximized using high-calorie formulas. Baseline dietary intake was lower in underweight patients than in normal-weight patients (mean percentage of the recommended daily allowance of calories, 89% vs 108%). Follow-up evaluation in normal-weight patients showed no change in percentage of ideal body weight for length. Follow-up evaluation in underweight patients showed improvement in mean dietary intake (from 90% to 104% of the recommended daily allowance of calories) and in mean percentage of ideal body weight for length after intervention (from 83.1% to 88.3%). Nutritional evaluation of patients with CHD demonstrated that underweight children had inadequate diets. Underweight patients with CHD who received nutritional counseling showed increased dietary intake and improved anthropometric measurements on follow-up.


Removing meconium from infant tracheae. What works best? At least nine mechanical devices are available for suctioning the tracheae of meconium-stained newborns. To our knowledge, the efficacy of these devices, as well as various suction pressures and patterns, has not been previously compared. We performed this investigation to assess these variables. Fourteen suction techniques (combinations of device, suction pressure, and suction intermittency) were evaluated sequentially in the trachea of each of 14 in vitro newborn piglets (1 to 4 days old); the order was randomized using a Latin square design. We chose three devices to compare: a meconium aspirator (Neotech Products Inc, Chatsworth, Calif), a hand pump (Res-Q-Vac, Repromed Systems Inc, New York, NY), and a 10F suction catheter (Superior Healthcare Group Inc, Cumberland, RI). Both the meconium aspirator and the hand pump were used with a 3.0-mm endotracheal tube. We instilled 0.8 mL of a homogeneous mixture of human meconium and saline (44 g of meconium per 100 mL of saline) in the trachea before applying each suction technique. The meconium aspirator and the suction catheter were each evaluated at three different vacuum pressures, -40, -80, and -150 mm Hg, using both continuous and interrupted suction. The hand pump was evaluated with one and two activations (one activation generates -100 cm H2O, according to the manufacturer). The percentage of instilled meconium recovered was consistently greatest (P less than .001) with the meconium aspirator (mean, 88.9% at -150 mm Hg, 84.9% at -80 mm Hg, and 73.5% at -40 mm Hg), intermediate with the catheter (mean, 81.0% at -150 mm Hg, 73.2% at -80 mm Hg, and 67.5% at -40 mm Hg), and least for the hand pump (mean, 67.9% with one activation and 72.6% with two activations). Recovery was better with continuous suction (P = .02) and increasing pressure (P less than .001). Among the techniques compared, the meconium aspirator at -150 mm Hg, using continuous suction, performed best in this model. It is unknown, however, to what extent the tracheal mucosa may be affected by this degree of negative pressure.


The development of thyroid storm in a child with McCune-Albright syndrome after orthopedic surgery. To report a case of thyroid storm that developed in a child with McCune-Albright syndrome after orthopedic surgery. The development of thyroid storm has not previously been described after surgery in a child. Descriptive case report. Pediatric intensive care unit. Patient with McCune-Albright syndrome who developed thyroid storm. SELECTION PROCEDURES AND INTERVENTIONS: Clinical features and treatment of thyroid storm are described. A highly sensitive immunochemiluminometric thyroid-stimulating hormone assay to help diagnose hyperthyroid states is also described. Before all operative procedures, children at high risk for thyroid dysfunction, including patients with McCune-Albright syndrome, should be screened and observed closely for the development of thyroid storm.


The pediatrician as expert witness. Participation and reaction to this activity. Little is known about the qualifications and motives of pediatricians who provide expert witness testimony. Pediatricians in Pennsylvania were surveyed anonymously to learn more about this practice. Two hundred fifty-five (49%) of 520 pediatricians responded, and 126 of these physicians had provided expert testimony at some time. Fully affiliated medical school faculty members were more likely to act as expert witnesses than were other pediatricians. Seventy-seven (61%) did so to defend a fellow physician. Only eight (6%) were listed with an organization that provides expert witnesses. Pediatricians were selective about their involvement as expert witnesses, and 96 (76%) had refused to give testimony at some time. Most were paid an hourly rate, which was in keeping with charges for medical consultation or lecturing. More than 80% of respondents were unhappy with the present system of procuring expert witnesses.


Twinning and neurologic morbidity.

Twinning and neurologic morbidity. To review the literature regarding neurologic morbidity among twins. Review of medical literature and data from the National Center for Health Statistics. The twinning rate is increasing concurrent with an increase in the survival of twins. Because twins are more often born prematurely and are of low birth weight, and premature infants are at increased risk for neurologic morbidity, twins are vulnerable to this problem. In addition, twins are more likely to develop brain abnormalities in utero, which is thought to be related to placental vascular anastomoses. Pediatricians should expect more twins in the future with congenital neurologic illness.


Reliability and construct validity of the Clinical Observations of Motor and Postural Skills. The Clinical Observations of Motor and Postural Skills (COMPS) is a screening tool for children with motor incoordination. A study of reliability (test-retest, interrater, and internal consistency) and construct validity with 132 children, both with and without developmental coordination disorder, is reported here. Test-retest reliability over 2 weeks was high: .92 for a group of 48 children. Interrater reliability for occupational therapists experienced in pediatrics was also excellent: .87 for a group of 72 children. Internal consistency of the COMPS was high, particularly when one of the seven items (Schilder's arm extension) was deleted. The test discriminates well between children with and without motor problems and has many properties of a good screening test.


Effects of aging on adult hand function. The effects that normal aging have on adult hand function and functional performance are not well understood. An empirical study was conducted examining relationships between prehension pattern type and frequency, hand strength, and performance time in functional tasks. Four groups of 10 adults were selected by age and gender, ranging from 24 to 87 years. Subjects were asked to pour milk into a cup and remove money from a wallet while being videotaped. Prehension patterns were identified with a functionally based classification system. Grip and three types of pinch were measured with a dynamometer and a pinch gauge. Prehension pattern selection did not seem to differ with age. Statistically significant differences in age were found for prehension pattern frequency, hand strength, and performance time. Nondysfunctional older subjects were observed resetting identical prehension patterns secondary to lateral pinch weakness, which contributed to increased prehension pattern frequency and performance time. Hand function seemed to remain stable until age 65 years, after which it diminished slowly. After age 75 years, age differences in performance were most apparent.


Performance of preschoolers on the Pediatric Clinical Test of Sensory Interaction for Balance. The purposes of this study were to describe the performance of 40 children aged 4 and 5 years on the Pediatric Clinical Test of Sensory Interaction for Balance (P-CTSIB) and to determine whether age- and gender-related differences were present. The P-CTSIB measures standing balance when sensory input is systematically altered. Kruskal-Wallis one-way analyses of variance by ranks (p less than or equal to .05) were used for comparisons by age and gender. When the 4-year-olds were compared with the 5-year-olds, significant duration differences were found in 4 of the 6 conditions in the heel-toe position of the P-CTSIB. The age-related differences on the remaining 2 heel-toe conditions, as well as on Condition 6 of the feet-together position, approached significance. Gender differences with 4-year-olds and 5-year-olds combined were statistically non-significant in all instances; however, girls performed better on 9 of the 12 conditions of the P-CTSIB. The results indicate that the feet-together position can discriminate between children without balance deficits and children with balance deficits. The heel-toe position is difficult for children aged 4 and 5 years without balance deficits and consequently has limited diagnostic value for this age group.


Dementia management: an occupational therapy home-based intervention for caregivers. This paper describes an occupational therapy intervention designed for family caregivers of persons with dementia. The intervention, based on the framework of a competence-environmental press model and the principle of collaboration, was implemented during 5 home visits. Each visit was designed to build caregiving skills through collaboration in identifying problem areas, developing and implementing environmental strategies, and modifying management approaches. A case vignette illustrates the therapeutic process and outcomes. The theoretical rationale and structure of the intervention and innovative documentation for evaluation of the theoretic process are also presented.


Test-retest reliability study of the Pennsylvania Bi-Manual Worksample. Test-retest reliability of a vocational assessment battery called the Pennsylvania Bi-Manual Worksample (PBWS) (Roberts, 1969) was examined in this study. The PBWS was administered to 30 adults with developmental disabilities at two different times, with an interval of 7 to 10 days between administrations. The subjects, who had mild to moderate degrees of mental retardation and ranged in age from 25 to 51 years, were chosen randomly from a group of 95 employees of a sheltered workshop for adults with developmental disabilities in western New York. When the scores from the two test administrations were compared to determine test-retest reliability, a high intraclass correlation value of .98 was found, which indicates that the PBWS provides consistent information about the vocational skills of adults with developmental disabilities.


Assessment of codependency behavior in two health student groups. The present study examines the relationship between codependency and caregiving to determine whether codependent persons tend to be attracted to caregiving professions. The study also examined the relationship between codependency, self-esteem, and locus of control, as measured by the Friel Co-Dependency Assessment Inventory (Friel, 1985; Friel & Friel, 1987), the Tennessee Self-Concept Scale (Fitts, 1965), and the Internal-External Locus of Control Scale (Rotter, 1966), respectively. Voluntary participants consisted of 15 occupational therapy students and 15 health information administration (HIA) students believed to be different from one another with respect to the caregiving aspects of their respective professions. The occupational therapy group scored significantly lower than the HIA group on the measure of codependency (m = 21.2 vs. m = 28.8, respectively) [t(28) = 2.258, p = 05]. No other significant differences were noted between groups for the other test scores. Only codependency scores between 31 and 60, that is, moderate-to-severe and severe concerns (n = 6), had a strong correlation with self-esteem scores (r = -.974) and a moderate correlation with locus of control scores (r = .683). No student in the occupational therapy group scored within the moderate-to-severe or severe range. The results did not support a relationship between codependency and choice of a caregiving-oriented profession. Further, only moderate-to-severe and severe codependency scores were indicative of low self-esteem and high external locus of control. Implications of this study suggest incorporation into the academic preparation of occupational therapy students information regarding codependency and self-assessment of codependency to facilitate awareness of the student's need to nurture others.(ABSTRACT TRUNCATED AT 250 WORDS)