[Ulcerative colitis and cancer].

[Ulcerative colitis and cancer]. We present two cases of ulcerative colitis complicated with rectum carcinoma, after ten years of the beginning of the illness. The author present 50 cases of ulcerative colitis treated in Bahía Blanca, Buenos Aires, Argentina between 1958 and 1986. In two of these cases we found the cancer localized in rectum (4%). The first was a 62 years old man, to have had a good post operative evolution with Miles operation. The second was a 56 years old woman who had a bad evolution with proctocolectomy and ileostomy, surviving 4 years with multiple metastasis. We recommend to perform an efficient control of the patients with more than ten years of evolution of the disease with colonoscopy and biopsies of mucosal of the colon and rectum, and C.E.A. echography, etc. We think that the technique of ileoanal-anastomosis with ileal reservoir is the best current method for the treatment of the cases of ulcerative colitis and cancer.


[Upper digestive hemorrhage in liver cirrhosis: clinical and endoscopic findings]. There are different opinions in respect to the main sources in upper gastrointestinal bleeding in hepatic cirrhosis. Some authors claim that ruptured esophageal varices are the cause of most of the hemorrhages. Recently, characteristic lesions have been showed in the gastric mucosa in portal hypertension (congestive gastropathy), and many believe that they are frequently the origin of the bleeding. We reviewed the records of 195 episodes of upper gastrointestinal bleeding in cirrhosis, with endoscopy performed within 12 hours of entry, and report here the endoscopic findings and the bleeding sites. We also investigated the relation between the etiology and functional class of the hepatic disease and the bleeding source. We observed variceal hemorrhage in 52.2% of cases; by gastroduodenal mucosal lesions in 13.8%; by gastric and duodenal ulcers in 13.8%; undetermined origin in 14.8% (due to coexistence of two or more lesions, without active bleeding). We found no differences between alcoholic and nonalcoholic cirrhotics in the bleeding sources. Furthermore, the bleeding sites were not different either in child A, B and C patients. In contrast, in major hemorrhages, esophageal varices were more frequently the origin (73.5%) than in minor ones (40.4%) (p < 0.002). The mortality was significantly higher in CHild C group (25%), than in groups B (14.3%) and A (2.3%) (p < 0.05 and p < 0.002, respectively). We recommend to carry out early endoscopy in every cirrhotic patient suffering from gastrointestinal bleeding, by skilled performers who are able to recognize the gastric red signs, before making a decision about potentially dangerous therapeutic measures, such as surgery, balloon tamponade, etc.


[A gastric multiple neuroendocrine tumor. A case report]. A 24-year-old woman underwent an upper digestive hemorrhage. Endoscopy revealed a triple, elevated, submucosal lesion. One of them was ulcerated. A Billroth type I gastrectomy was performed. Post-operative course was uneventful and the patient remained asymptomatic for eighteen month. Histology revealed a monomorphous cellular proliferation, with a rosette-like pattern in some areas and trabecular in others. Histochemical methods confirmed the diagnosis. This one is an infrequent lesion; 0.02% of all gastric tumors. Some research studies have related this kind of tumors with prolonged ingestion of H2 inhibitors and others antacid. These tumors stem from Kultschitzky cells coming from the neuroectoderm. They are scarce in stomach; thus these tumors become infrequent. Effective treatment is endoscopy removal of pedunculated lesions or surgery for the bigger ones.


[Patients with panic disorder: a 5-year follow-up study]. The present study is aimed at assessing a 48-outpatient sample that had been diagnosed as Panic Disorder cases: Approximately 5 years ago, patients had been treated with either Alprazolam, Imipramine or placebo during an 8-week double-blind trial. (The original study was part of the International Study on Panic Disorder--see León C. A. et al., Acta Psiquiát Psicol Am Lat, 1990, 36 (1/2), 59-72). Course, as well as clinical evolution of disorders, and changes occurred during that period, such as remission, or persistence of initial symptoms, are worth being noted. On the other hand (a) the efficiency of the original treatment, (b) the subsequent resorting to other treatments, and (c) differences observed among patients that have been grouped according to the medication they had been given during the original trial, are to be emphasized.


[Witch hunt].

[Witch hunt]. Owing to its sinister characteristics, as well as its temporal pertaining to the Modern Age, the Witch-Hunt historical episode has become an embarrassing affair for our supposedly rational beings' self-esteem. Long lastingly, therefore, Witch-Hunt has been either overpassed straight away or just attributed to violent and pathological a manifestation of collective craze as its own name indicates. Lately, though, many authors have met the challenge of finding out a rational background thereof, actually unearthing coldly calculated, relentlessly pursued outweighing political and economic interests. It is the author's contention that a serene, diligent consideration of all hypotheses that have been set before the connection with this episode--together with their very inherent disparities--could (apart from their own heuristic values) contribute eventually to both sharpening and broadening the understanding of our human condition, complex and fragile as it is.


[Psychiatry in ancient Mexico].

[Psychiatry in ancient Mexico]. Using studies on prehispanic and early post-conquest documents of Ancient Mexico--such as the Badianus Manuscript, also known as Libellus de Medicinalibus Indorum Herbis, and Brother Bernardino de Sahagún's famous work History of the Things of the New Spain, a description of some existing medical and psychiatric problems, and treatments Ancient Aztecs resorted to, is presented. The structure of the Aztec family, their problems with the excessive ingestion of alcoholic beverages, and the punishments native authorities had implemented in order to check alcoholism up are also described.


[Death causes in 428 alcoholic patients: a descriptive study]. Several studies have demonstrated either a direct or an indirect relationship between alcoholism and death causes. The present paper is a descriptive study about death causes in 428 alcoholic patients from San José, Costa Rica, metropolitan area, whose death occurred between 1978 and 1988. Sample subjects were males, under 90-year-old at death time. It was found out that basic death causes were: Traumatism and poisoning, 25%; circulatory system illnesses, 20%; digestive system illnesses, 18.5%, and tumors, 15%.


[Borderline personality disorder: a comparative study between the clinical diagnosis and the Rorschach test]. Diagnostic concordance among Rorschach Test, clinical approach and DSM-III-R criteria for BPD is studied in an inpatient sample. A low degree of concordance among the three diagnostic systems was found. Two among 8 DSM-III-R criteria (physically self-damaging acts, and unstable-intense relationships) were the most discriminating symptoms for diagnosing BPD. The importance of considering the diagnostic efficiency of each DSM-III-R criterion is discussed. The most frequent concurrent diagnosis along with BPD were: Affective, and psychotic disorders. Their relationship is analyzed.


[Spinal anesthesia at T12 or T10 level with hyperbaric bupivacaine 0.5%: value of determining the useful dosage according to the weight]. A retrospective study was carried out on anaesthetic records concerning spinal anaesthesia with hyperbaric bupivacaine 0.5% in urologic surgery. Three doses were utilised: slight (< 0.19 mg.kg-1), mean (0.19-0.21 mg.kg-1) or important (> 0.21 mg.kg-1) for two different levels: T12 or T10. Important doses may be involved excessive extension. Failures are perhaps more frequent with slight doses. Mean doses, 0.20 mg.kg1, seems to be recommended.


[Towards a day care hospital. V. Does repetition of the Newman test induce learning?]. Newman's test consist in draw a line on two parts of a figure made of points. This test was achieved in four successive trials by thirteen boys and fourteen girls, all voluntary students. In two trials subjects wear Reiser screen which reduce to a slight extent distinctness of vision. Trial order was randomised. For each trial, time performance and four numeral criterions of graphic defects were compared to initial values. The test retest values are no significantly different. Reiser screen alter some criterions. So the Newman test is useful to assess awakening on condition that such criterion were used in reference to subject preanaesthetic values and with controlled conditions of environment.


[Cardiac arrest and epidural anesthesia]. A man 55 years old reached of chronic bronchopneumopathy was underwent a subumbilical surgery under an epidural anesthesia. The puncture has been realized at the level of the space L3-L4, with the location of an epidural catheter after negative aspiration test. The local anesthetic with lidocaine 2% (12 ml) Ten minutes later, the patient presented cardiac arrest that evaluated favourably under the cardiocirculatory intensive care. Blood and LCR analysis exclude the eventuality of a toxic accident, an anaphylaxia or spinal anesthesia.


[Factors changing the length of analgesia in spinal anesthesia]. So as to determine the effects of some factors on the duration of bupivacaine spinal anaesthesia, a prospective controlled study was carried out on 152 ASA I or II patients. They were randomly allocated to six groups. The patients of group I were given 4 ml of 0.5% bupivacaine at 27 degrees C. The patients of group II were given 4 ml of a mixture including 3 ml of 0.5% bupivacaine, 1 ml fentanyl in 1 ml of 10% dextrose solution. The group III was given 4 ml of a mixture including 3 ml of 0.5% bupivacaine, 0.20 mg adrenaline. The group IV was given 4 ml of a mixture including 3 ml of 0.5% bupivacaine, 0.15 mg clonidine. The patients of group V were given 4 ml of 0.5% bupivacaine at 20 degrees C and those of group VI were given 4 ml of 0.5% bupivacaine at 5 degrees C. There is significant difference between regression times of sensory analgesia of group II and group I, group IV and group III, group VI and group V. The choice of product to lengthen analgesia in spinal anaesthesia depends on the use of each anaesthesist, the characteristic of patients and the duration of surgery.


[Our experience of infectious risk in prosthetic breast surgery]. This retrospective clinical study was made to help determine the signs of infectious or healing problems in candidates for prosthetic breast surgery. It concerns 80 patients with 108 breast implants (44 breast reconstructions, 21 cases of hypoplasia, 8 breast asymmetric, 20 secondary procedures, 15 of them being changes of expansion implants by definitive implants). Thirty one infectious complications (28.7%) were noted. In 22 cases it consisted of a resolutive hyperthermia. Nine cases of local complications were noted, with four implant exposures (3%). Bacteriological samples were analyzed and were positive in four out of nine (Staphylococcus aureus). In 8 out of the 9 cases the initial procedure consisted in a breast reconstruction. All 8 patients underwent postoperative radiotherapy after the initial mastectomy (Patey). The implant type (implantable, pre-filled, expansion prosthesis), its location (retromuscular), the type of surgery (asymmetrical breast musculocutaneous or fasciocutaneous flap) don't seem to be responsible in the genesis of the complications. This retrospective study could not help determine which protocol of antistaphylococcal antibiotherapy suits lest. Infectious problems arose with or without antibiotics.


[Pseudomonas aeruginosa and beta-lactam resistance phenotypes (Tunisia 1989-1990)]. 366 strains of P. aeruginosa were studied. More than half of samples were issued from urology (40%) and general surgery (21%) and samples are mostly urine specimens (46%). The phenotypes of resistance to 3 beta-lactams (respectively ticarcillin, cefotaxime and ceftazidime) showed that 73% of the strains were wild phenotype (SSS-SIS-SRS). The MIC of ticarcillin +/- clavulanic acid, azlocillin, cefoperazone, cefsulodin, cefotaxime and ceftazidime against 93 strains chosen among different phenotypes of resistance showed that ceftazidime is the most active beta-lactam, 93% of strains being inhibited by 16 micrograms/ml. These MIC and iodometric test performed on 33 strains with ticarcillin MIC > 128 mg/l showed that acquired resistance was non enzymatic in 21% of cases and was related to beta-lactamase production in 79% of cases.


[Bacteriological efficacy of the main treatment procedures of urban waste water]. Bacterial contamination of raw and treated wastewaters has been studied for 15 purification plants. Results have permitted the evaluation of bacterial effectiveness of different treatment modes. Best elimination rates of indicators (faecal contamination test-germs) were obtained by extensive treatments. Aerated lagoons were not usually more efficient than natural ones. Oxidation ditches were classified after stabilization ponds with a bacterial reduction of 2 log units. Biofiltration seemed to have the same effectiveness than activated sludge which were slightly more efficient at low-charge. Global elimination of Faecal contamination test germs by conventional intensive treatments is 1-2 log units.


[Effects of nitrogen nutritional deficiency on the distribution of particular lipids in a eutrophic lake milieu]. The seasonal distribution of particulate lipids coupled with N-nutrient availability was studied in eutrophic Lake Aydat (Massif Central, France). The concentrations of lipids ranged between 196.9 and 2971.5 micrograms.l-1 (mean +/- s.d. = 1090.1 +/- 705.5 micrograms.l-1. Lipids were abundant in summer and fall when nitrates were insufficient reflecting thus an orientation of cell metabolism towards an accumulation of storage products. In such conditions, the heterocystous Cyanobacteria were found to develop due to their competitive advantage of exploiting atmospheric nitrogen. Their lipid metabolism did not seem to be affected at least partially by NO3- exhaustion.


[The PB IMC bovine pericardial prosthesis: 11 years in the mitral position. Instituto de Moléstias Cardiovasculares]. To evaluate the postoperative results of patients with valvular bovine pericardium prosthesis in mitral position. From 1977 to 1988, 10.812 bovine pericardial valves were produced by IMC Biomédica and implanted. Our group at IMC implanted 1,193. Of the 663 patients with mitral change, 586 were adults and 77 were youngsters (under 21). The rheumatic fever was the most frequent primary cause of valvar disease (76.5%). The stenosis (23.0%) and the insufficiency (20.7%) were the most common of the damages that led to mitral exchange. We studied 602 patients that left the hospital, representing 666 bioprostheses in 11 years. The surgeries were performed with standard cardiopulmonary bypass with crystalloid cardioplegia in the first seven years and hypothermic or normothermic blood cardioplegia enriched with amino acids in the last four years. Hospital mortality was 9.2%; 13.2% for the first 5.5 years (group I) and 6.3% for the last 5.5 years (group II). Eleven-year follow-up was 98.8% and the mean time was 3.8 years. The actuarial study showed a survival rate of 74.3 +/- 6.5% for the youngsters and 73.0 +/- 3.7% for the adults, with 95.0 +/- 1.0% of the patients free from valve-related fatal complications corresponding to one event % patient-years (endocarditis 0.6%; calcification 0.1%; thromboembolism 0.3%). The actuarial rate of non fatal valve-related late complications was 55.2 +/- 8.6% of patients free from all complications, corresponding an incidence of 2.9%/patient-year (endocarditis 0.5%; calcification 1.8%; thromboembolism 0.3%; periprosthetic leakage 0.2% and rupture 0.08%). In this period 95.8 +/- 1.6% of the patients were free from thromboembolism; 99.1 +/- 0.6% free from rupture; 90.1 +/- 4.08% free from endocarditis in the young group (1.5%/patient-year) and 95.2 +/- 1.03% for adults (1.0%/patient-year). For calcification, the actuarial rate was 43.1 +/- 12.3% for youngsters (7.5/patient-year) and 68.8 +/- 9.3% for adults (1.1%/patient-year). IMC pericardial bioprosthesis performed well in a period of 11 years with low rates of fatal complications; ruptures and thromboembolism without the use of anticoagulants. Calcification was the major complication mainly in youngsters.


[Staphylococcus aureus in the hospital milieu]. This study concern the distribution and sensibility towards some antibiotics of 318 Staphylococcus aureus strains isolated in bacteriological samples coming from la Rabta hospital units. The study of distribution shows that 75% of these strains are isolated in bacteriological samples coming from surgery and intensive care unit dermatology unit, and ear nose and throat unit. The bacteriological samples are matter, blood, and intensive care materials. The study of sensibility found a high frequency of methicillin resistant Staphylococcus aureus. These strains are also resistant towards macrolide and lincosamide. MLSB resistance is the predominant phenotypic aspect. It was also observed that all of Staphylococcus aureus gentamicin resistant strains were also resistant toward methicillin. At last is seems that pritinamicin, sulfamethoxazole-trimethoprim, and ofloxacin, are good alternatives for treatment of staphylococcus aureus infections diseases.


[Endovenous thrombolysis in acute myocardial infarct. The experience in a community hospital. An analysis of 120 patients]. To demonstrate the experience with thrombolytic therapy in a community hospital without a cardiac catheterization laboratory. One hundred and twenty patients with EKG evidence of acute myocardial infarction with less than 6 hours of pain entered the study. They were retrospectively subdivided into two groups: group 1 (n = 96) received streptokinase and group 2 (n = 24) received rt-PA. One hundred and twenty patients were analysed. Ninety six (80%) received SK and 24 (20%) received intravenous rt-PA. Infarct side was anterior in 57 cases (47.5%) and inferior and/or lateral in 63 (52.5%). Coronary-angiography performed prior the discharge in reference hospital demonstrated patency of culprit vessel in 69 patients (80%) treated with SK and in 22 (91%) treated with rt-PA. According to clinical and angiographic data 60 patients (50%) were managed with medical treatment, 31 (25.8%) were submitted to angioplasty of the culprit artery and 29 (24.1%) underwent coronary bypass surgery. The complications were intracranial hemorrhage in 2 cases (1.6%), 1 post SK (1.0%) and 1 post rt-PA (4%); both of these patients died; reinfarction occurred in 4 patients and in 3 of them SK infusion was repeated successfully. There were no reinfarction in patients receiving rt-PA; major bleeding requiring blood transfusion occurred in 2 patients (1.6%); 1 patient developed hemothorax post SK and another one treated with rt-PA developed hematoma of left inferior limb. Eleven patients (9.1%) died during the hospital stay; 2 patients died of intracranial hemorrhage, 7 of cardiogenic shock and 2 had sudden death. The mortality rate in patient with anterior wall infarction was 15.7%, whereas it was significantly lower in the remaining patients (3.1%, p < 0.05). Only 4 patients over the age 75 received thrombolysis and 2 of them (50%) died. Intravenous thrombolytic therapy was safe and feasible in a community hospital without cardiac catheterization facilities. We observed only 2 fatal complications (1.6%) directly related to drug management (intracranial hemorrhage). The hospital mortality was 9.1%, including patient undergoing angioplasty of surgery following thrombolytic therapy.


[Value of waste water in agriculture. Evaluation of soil bacterial contamination, water table and plant culture]. The present study aim was to valorize the treated waste water as source of fertilizers for vegetables seed production and to assess the eventual bacteriological contamination risks of soil, plant and phreatic ground water table. The bacteriological analysis of drained water did not reveal any fecal coliforms vertical migration in depth and a low fecal contamination (thermotolerant coliforms) is limited to the levels of superficial horizons. The seed produced by using waste water showed a slightly fecal contamination which disappeared following treatment with a (5% chloride solution. The treated waste water improve the onion seeds production per hectare in spite of the increases of the phytopathogenic hazards.


[Total mercury levels in certain coastal fish]. In this study, we decided to scan some common edible fish species and find out by atomic absorption spectrophotometry their total mercury content, in order to have an idea on their contamination degree and know whether they are edible or can be risky for consumers. The results of our investigations gave us the evidence that total mercury content of several fish species catched at different tunisian harbourgs is beyond the WHO recommended maximum level, and thus, consumption of such fish is harmless.


[Multidisciplinary experience in the approach to the hypertensive patient]. To evaluate the impact of the educational activities on the approach of patients with hypertension, with an interdisciplinary team. Fifty patients divided into two groups: A) with 25 patients who participated in educational activities in the Hypertension League (HL) and B) who were also registered and did not take part in the activities. They were studied regarding blood pressure (BP), weight control, smoking habits, alcoholic beverage consumption, physical activities and frequency of medical care. There was a drop in BP of 84% of the patients in group A and 88% in group B, a drop in weight in 60% of group A and 44% of group B. We registered the presence of 4% of smokers in group A and 16% in group B. Physical activities were regular in 56% of group A and 36% in group B. Absenteeism to meetings was slightly higher among group B (44%) when compared with group A (30%). In spite of not having observed any significant differences between both approaches, regarding to strict BP control, we were able to observe a noticeable advantage in favor of the educational approach to the group, with participation of interdisciplinary team.


[The heart transplant. The initial experience of the Instituto do Coração de Pernambuco]. To describe the initial experience of a heart transplant program in Recife, Pernambuco. Six patients in the final stage of heart failure were submitted to heart transplant. There were 4 male and 2 female patients, ranging in age from 15 to 61 years (mean, 43.8). Four had coronary heart disease and two dilated cardiomyopathy. The conventional operative technique of orthotopic heart transplant was used. All patients received a triple drug immunosuppressive therapy. There was one death due to acute rejection on the 28th postoperative day. The 5 survivors are in functional class I in a mean follow-up period of 113 days. The initial experience of a heart transplant program in Recife, Pernambuco, suggests that good long term results could be expected.


[Directional coronary atherectomy. The initial experience]. Four male patients, 38 to 59 years old (mean 49 +/- 2.5), with angina and the angiographic features has been the classical indications for the method, underwent directional coronary atherectomy. Vessels treated were, respectively, left anterior descending artery (LAD), right coronary artery (RCA), saphenous vein graft (SVG) to LAD and SVG to left marginal branch. Reductions to 50% or less of the internal diameter was considered a satisfactory result. Early success was obtained in all four patients. Obstructions of 75 to 95% (mean of 83 +/- 7.5%) were reduced to 0-25% (mean 12 +/- 5%) after atherectomy. Only one patient died suddenly five days after de procedure. So, directional coronary atherectomy may represent a reliable and safe method for special situations.


[The clinical characteristics of patients with an acute myocardial infarct associated with nonobstructive coronary arteriosclerotic disease in a Brazilian community]. From 404 patients with acute myocardial infarction, 14 (3%) had coronary lesions considered not obstructive (lesion < 70%) and 4 had chronic Chagas's disease. This study suggests that acute myocardial infarction without coronary obstruction had particular feature in the Brazilian population.


[Acute myocardial infarct in a patient with dextrorotation]. A 79-year-old woman developed myocardial infarction associated with acute pulmonary edema. The electrocardiogram recorded QRS complex of QS type in V1 with upper ST extending from V3R to V6R. The polarity of the P wave in bipolar leads was positive, so compatible with dextrorotation complicated by myocardial infarction. The dextrorotation was confirmed with chest roentgenogram and echocardiogram.


[Coronary angioplasty in patients over 70. An analysis of 115 dilatations]. To verify the validity of transluminal coronary angioplasty (PTCA) in the population over 70 years old. Retrospectively, were analysed 115 PTCA performed in 89 elderly patients (70 to 85 years old) from January 1988 to January 1991. Three groups were defined: A) single vessel-77 (86.5%) patients; B) double vessel-9 (10.1%) patients; C) three vessel-3 (3.4%) patients. Of the 89 treated patients, 81.8% in group A, 72.2% in group B and 75% in group C were successfully dilated. The learning curve had showed increase in success rate after the first 250 angioplasties (from 60.6% to 82.5%). Treatment of acute myocardial infarction by direct thrombolysis was made in 7 patients (6 S, 1 I). Major complications included: deaths (4.4%), ventricular fibrillation (1.08%), acute coronary occlusion (6.6%). Emergency coronary artery bypass grafting was required in 4.4% with one death. Coronary angioplasty is an effective treatment in elderly patients and may be performed with acceptable success and with low complications.


[Coronary angioplasty in octogenarians]. To evaluate the indications, results and follow-up of patients with 80 years old and over, who had undergone percutaneous transluminal coronary angioplasty (PTCA). From July 1987 through July 1990, 36 patients, 80 years of age and over, had PTCA as an alternative method to treat coronary artery disease. Their age ranged from 80 to 85 (mean = 83) years. Twenty five were male. Significative obstruction was considered when 70% or more of the internal diameter was stenosed. Satisfactory results were achieved when reduction of 50% or more of the coronary artery obstruction was obtained. In 34 of 36 patients (94.4%), PTCA was successfully performed. Forty four of 46 coronary arteries were successfully dilated. One patient had acute coronary occlusion with acute myocardial infarction treated clinically. There were no emergency surgeries or early deaths. Clinical follow-up was obtained in 15 of the 34 patients. Four had repeated coronary arteriography (at 1, 3, 6 and 12 months after primary PTCA) due to angina. Two of them had restenosis and were successfully redilated (the patients restudied at 3 and 6 months, respectively). Within a mean clinical follow-up period of 9.6 (ranging from 1 from 21) months the following features were observed: two of 15 patients (13.3%) had acute myocardial infarction and were clinically followed; late death occurred in 3 patients (20%) with only one related to cardiac events. Survival has been observed in 12 of these 15 patients (80%). PTCA represents an alternative, safe and effective invasive procedure to treat octogenarians with coronary artery disease.


[The use of acetylsalicylic acid as a platelet antiaggregant]. To comprove the efficiency of acetyl salicylic acid (ASA) as platelet antiaggregant drug, a 100 mg/day dose base. Two hundred and fifty-eight patients were studied between 1988 and 1990. Platelet functions were measured using an aggregometer plus ADP 5 as platelet aggregation inductor. Two groups were studied: 1st group, using ASA (111 patients), 91 hypoaggregants; 2nd group, not using ASA (147 patients), 120 normals, 12 hypoaggregants and 15 hyperaggregants. From the 2nd group, 91 had another evaluation under the use of ASA and showed a clear effect of the drug. The use of aspirin, 100 mg/day dose, is enough to reduce platelet antiaggregation.


[Aortic dissection associated with systemic lupus erythematosus]. A 33-year-old female patient, with a 4-year history of hypertension plus a 3-year history of systemic lupus erythematosus, who had been taking high dosages of corticosteroids, has shown repetitive respiratory infections and congestive heart failure for the past 8 months. Angiocardiography confirmed the diagnosis of aortic insufficiency with aneurysmatic dilation of Valsalva's posterior sinus, ascending aorta of normal diameter and normal coronary arteries. Aortic dissection causing aortic insufficiency due to collapse of aortic leaflets was spotted during the surgery and was corrected by a bovine pericardial tube and suspension of aortic valve. The postoperative (PO) period was complicated by left-sided seizures followed by left hemiparesis and respiratory infection. She was discharged on the 25th PO day with mild left hemiparesis and in functional class I (NYHA), using medicines. We emphasize the need to consider the diagnosis of aortic dissection in patients with systemic lupus erythematosus and aortic insufficiency, specially in those who have a history of systemic arterial hypertension and long-term corticosteroid therapy.


[The importance of the early diagnosis of infectious endocarditis in an aortic prosthesis by transesophageal two-dimensional Doppler echocardiography]. A female patient, 21 years old, was submitted to surgical treatment of severe aortic insufficiency. She was doing well until the 9th postoperative day, when she presented sepsis and an embolic cerebrovascular attack. The transesophageal echo-Doppler-cardiogram showed paraprosthetic abscess and vegetations, that were not seen on the transthoracic echo-Doppler-cardiogram performed one day before. We are convinced that the findings on the echocardiogram were very important for the good results obtained by the prompt surgical procedure.


[A cardiac lesion secondary to paraquat]. To evaluate cardiac alterations secondary to exogenous intoxication by paraquat. We performed analysis of clinical and laboratory data of 25 patients with acute paraquat poisoning admitted in our ICU from November 1983 to January 1991. There were purposeful overdoses in 24 cases (96%). The mortality rate was 56%. The lung involvement was 96%, renal was 92%, gastrointestinal tract was 72%, hepatic was 56%, and cardiac involvement was 40%. Cardiac involvement due to paraquat is frequent (40%). The clinical picture of this involvement has a wide spectrum, ranging from minimal changes in the ECG to acute and extensive myocardial necrosis.


[The surgical treatment of nodal reentry tachycardia. The late results]. To analyze the long-term results of surgical treatment of atrioventricular nodal reentrant tachycardia (AVNT). From March 1987 to March 1990, 20 patients with AVNT were submitted to surgical therapy, 14 female, aged 12 to 70 (42.8 +/- 17) years. All presented crisis of AVNT from 6 months to 60 (18.4 +/- 15.9) years. Ten of them had syncope or near syncope and two with cardiac arrest during reversion of AVNT with antiarrhythmic drugs. They used 1 to 6 (3.75 +/- 1.45) antiarrhythmic drugs before surgery. The electrophysiologic study (EPS) showed the common form of AVNT in all cases. The surgical procedure was anatomically directed to the posterior area of the AV node. Programmed atrial stimulation (PAS) were applied on 18 patients after surgery. The long-term results were analysed by clinical evaluation, EPS and Holter when they were necessary. The postoperative PAS was done in 18 patients and did not induce any AVNT, even after atropine IV. The PR interval was 153 +/- 50 ms before and 152 +/- 38 ms after surgery (p > 0.05). During follow up (26 +/- 10 m) there were not AVNT recurrence. Two patients developed chronic atrial fibrillation after 24 months of surgery. The perinodal dissection technique used was safe and successful to treat AVNT, preserving AV nodal conduction.


[The functional expectations of valve bioprostheses. I. Physical and histopathological tests for the use of sections of bovine pericardium]. The heterogenicity of the bovine pericardium sac regarding its elasticity, extensibility and thickness encouraged the work with the purpose to study the different areas of pericardium, mapped according to its position on the heart. Ten bovine pericardium sacs previously selected and obtained at the slaughterhouse immediately after the animal slaughter were utilized. The pericardia were sectioned sagittally from the anterior to the posterior portion, thus obtaining two parts, right and left. Two areas were demarcated for each one of them amounting to four regions: A, B, C and D. Each of the four regions was divided into two regions: 1 and 1, amounting to 80 samples. There have been physical tests (shrinkage and mechanical resistance), histopathological studies and statistical analysis were done. The right ventricle area (region D) had the best utilization (21.3%), and then the left ventricle area (region B, 16.2%). The physical tests on the utilized samples showed minimum and maximum values of 0.20 and 0.40 mm for the thickness, 2.0 and 7.0 kgf for force, 1.6 and 4.2 kgf/mm2 for rupture, 18 and 36% for stretching, 15 and 65 for tenacity index and 85 and 87 degrees C for shrinkage. The region D presented histologically and more preserved, either for the collagen fibers or the elastic ones. The results of the statistical analysis proved the need to increase the sample size to certify the existence of a sectioning of the pericardium and a more adequate position of the proof body (longitudinal, transversal and oblique) when obtaining the pericardium flap to make the valve bioprosthesis.


[An anatomical study of the proximal portion of the internal thoracic artery]. The internal thoracic artery was studied because of its recent use in the revascularization of the myocardium of patients having coronary artery disease. The artery of 50 cadavers of adult individuals, 22 (44%) females and 28 (56%) males, whose age ranged from 20 to 84 years, was studied after neoprene latex injection. The specimens were fixed in 10% formaldehyde solution and dissected macroscopically and mesoscopically, seeking the origin of the artery, its relation to the phrenic nerve and the origin of the pericardiophrenic artery. The origin of the internal thoracic artery is much more frequent isolate (80%) than in a common trunk with other arteries (20%) from the subclavian artery. The left and right phrenic nerves cross anteriorly the artery in 54% of the cases; posteriorly in 14%; the right nerve crosses it anteriorly and the left posteriorly in 22%; and the reverse occurs in 10%. The pericardiophrenic artery is a branch of the internal thoracic artery in 99% of the cases and the average distance between the origins of these two arteries is 3.9 +/- 1.3 cm. The internal thoracic artery originates isolatedly from the subclavian artery in 80%, and the left and right phrenic nerves cross it anteriorly in 54% of the cases. The pericardiophrenic artery is a branch of the internal thoracic artery in 99% of the cases.


[An extracardiac valved graft in the establishment of continuity between the right ventricle and the pulmonary arteries. The technics and the results of their use in correcting common truncus arteriosus]. To evaluate the results of valved extracardiac conduits for establishment of right ventricle pulmonary artery continuity in patients with truncus arteriosus communis. between January 1981-January 1991, 15 patients with persistent truncus arteriosus communis underwent surgical repair with valved extracardiac conduits for establishment of right ventricle-pulmonary artery continuity. Mean age was 2 years 9 months and mean weight 9.6 kg. Eight patients were females and seven males. The diagnosis was established by hemodynamics and/or echocardiographic studies and surgical indication was based in presence of cardiac insufficiency and prevention of pulmonary vascular disease. Valved conduits were performed with insertion of pericardial xenograft in woven dacron prosthesis. Diameters ranged between 12 to 22 mm. The in-hospital mortality was 33% and the low output syndrome was the main cause. Post-operative complications, with variable gravity, occurred in 80% of the patients. Reoperation occurred in four patients during the long term follow-up due to stenotic complications of the valved conduit, mean 5 years 2 months after implant. Late mortality was 30%, with correspondent actuarial life table of 66.6% in 1st year, 53.3%, 3rd and 46.2% in 5 and 10 years. Although the valved extracardiac conduits have significantly improved the survival of patients with truncus arteriosus communis, late stenotic complications were high determining continuous development of direct ventricle-arterial anastomosis techniques.


[Percutaneous transluminal coronary angioplasty in patients with prior surgical revascularization]. To show the author's experience with percutaneous transluminal coronary angioplasty (PTCA) in patients with prior coronary bypass surgery. Between January 1989 and January 1991, 629 PTCA in 572 patients were performed. Forty-eight had previous revascularization surgery with interval range of 4 days to 10 years. The PTCA sites were divided in three groups: A) native arterial segments, not affected by surgery (26 patients); B) native arterial segments proximal (4 patients) and distal (2 patients) to graft anastomosis; C) in the coronary vein graft (16 patients). The overall primary success was 78%. In groups B and C, 16 procedures were successfully dilated (72%). All failures in group C were due to unstable problems in reaching (4 patients) or crossing (2 patients) the stenosis with the balloon. There was one death in group A and another in group C. Angioplasty is an effective alternative for treatment of recurrent ischemia in patients with prior myocardial revascularization surgery and in early results are comparable to the general angioplasty population.


[The pattern of the clinical use of digitalis. The need for a reassessment]. To evaluate the pattern of utilization of digitalis in an academic hospital. Clinical files of all patients admitted in medical wards at the Hospital de Clínicas de Porto Alegre were studied. Data were collected during five different days, three in the winter and two in the summer, keeping an interval of at least two weeks between each data collection. Heart failure diagnosis was evaluated objectively by means of a score proposed by Carlson et al. From a total number of 881 patients, 114 (13%) were receiving digoxin. Mean age was 66 +/- 13 years and 47% were males. Considering the patients who were taking digoxin, 32% presented scores compatible with definite or possible heart failure; 26% had atrial flutter or fibrillation; 18% had heart failure and supraventricular tachyarrhythmias; and in 24% no clear indications were found according to our criteria. Previous use of digoxin was found in 85% of the patients and 32% were withdrawn during the hospitalization. Considering just the patients who had no reason for using digoxin, only 44% had the drug withdrawn. According to current criteria, many hospitalized patients receive digoxin without a definite indication. These data suggest that reassessment of the use of digitalis should be incorporated into clinical practice.


[Familial complete atrioventricular block in patients with hypertrophic cardiomyopathy]. The association of spontaneous complete heart block and hypertrophic cardiomyopathy is rare. We have studied three patients of the same family, two brothers and one nephew, ages 19-41 years, with hypertrophic cardiomyopathy confirmed by hemodynamic and angiographic studies. All patients were treated with permanent cardiac pacemaker implant. They are asymptomatic, aging 33 to 55 years, with follow-up of 157 to 176 months after the onset of the heart block.


[Pulmonary valvuloplasty with a balloon catheter in calcified pulmonary valve stenosis]. Since the first pulmonary valvuloplasty report, the procedure has been used frequently, becoming the best option in isolated valvar pulmonary stenosis. Pulmonary valvuloplasty in adults with calcified valvar pulmonary stenosis, however, has been minimal. We have reported the case of a 62-year-old female patient, with calcified valvar pulmonary stenosis, who underwent valvuloplasty with balloon catheter and showed a decrease in the transvalvular systolic gradient, thus proving the success of post procedure.


[The dilatation of the residual stenosis due to a Blalock-Taussig anastomosis by percutaneous transluminal angioplasty]. A ten-months-old white infant had undergone surgical modified Blalock-Taussig anastomosis at 2 months of age. An interposition of bovine mammary artery was anastomosed with the right subclavian artery. A satisfactory clinical follow-up after surgery was achieved, until the last three months when cyanotic spells were observed. A new angiographic study showed tricuspid and pulmonary atresia and severe stenosis (+/- 80%) at the anastomosis between the subclavian artery and the bovine mammary tissue. Percutaneous transluminal angioplasty was successfully performed. An immediate improvement of cyanosis and oxygen saturation were observed.


[Ostial occlusion of the left coronary artery in a female patient with chronic stable angina. The coronary cineangiographic aspect]. The left main coronary artery occlusion is the most dangerous presentation of arteriosclerotic coronary artery disease, often resulting in hemodynamics and electrical instability that ultimately lead to death (fatal acute episodes and/or sudden death). A 47-years-old female with multiple risk factors went on a cardiologic check-up, including coronary angiograms, as a preoperative evaluation of a routine abdominal surgical procedure. The angiograms provided definite information about the coronary vessels including total occlusion of the ostium of the left main coronary artery (LCA) and collateral circulation from the right coronary artery (RCA). The RCA was dominant and normal. The left ventriculogram showed hypertrophy but the left ventricular function was normal. These clinical and angiographic findings were analyzed at a surgical-clinical session and a coronary artery bypass graft operation (myocardial revascularization) was done.


[The transesophageal echocardiographic diagnosis of left ventricular myxoma]. A 35-year-old man with cerebral vascular accident due to a left ventricular myxoma, had his diagnosis cleaned up by the transesophageal echocardiography. The patient underwent heart surgery to remove the tumor. The final pathologic diagnosis was therefore pedunculated thrombus of the left ventricle although the clinical findings and gross morphologic features of the mass were highly suggestive of myxoma.


[The electrocardiogram in endomyocardial fibrosis]. To detail the most common electrocardiographic findings on the endomyocardial fibrosis and to correlate with the ventricular form. One hundred patients with endomyocardial fibrosis (68 female) with ages between 5 and 64 years old (mean 34 years). According to ventriculographic aspect the patients were divided in three groups: group I--11 patients with predominant right ventricular compromise; group II--58 patients with biventricular involvement, but not necessarily similar in intensity; group III--31 patients with predominant left ventricular compromise. On patients with predominant right ventricular compromise, the electrocardiographic pattern was of QRS complex of low voltage in the frontal plane, presence of incomplete right bundle block and QRS complex with low voltage and with qr or qs aspect in V1 contrasting with QRS complex of great amplitude on V2 and V3. Left anterior hemiblock, aspect of inactive area, and R waves of high voltage on left precordial leads were observed on patients with predominant left ventricular involvement. The electrocardiogram of endomyocardial fibrosis, in spite of inespecific, may help in the identification of ventricular involvement.


[The usefulness of digital angiography in performing coronary angioplasty. An analysis of 100 cases]. To analyse the actual contribution of digital angiography in the angioplasty setting and to assess its utility to optimize angioplasty results. One hundred patients with single vessel coronary artery disease, without previous angioplasty or coronary artery bypass graft surgery, who underwent angioplasty from January to December 1990. Views were obtained in standard films and also in digitized angiograms. The latter was acquired before angioplasty in order to precisely quantify the stenosis and also to measure the reference diameter of the artery that was used and to choose the balloon catheter for each case. New acquisitions were done during and after the end of the procedure to confirm the residual stenosis and to measure the final diameter. The mean stenosis pre angioplasty was 78.2%, the mean reference diameter 2.8 mm and the mean diameter at the stenotic site 0.8 mm. The balloon artery relation was 0.9:1. After angioplasty the residual stenosis was 13.6% and the dilated segment had a final diameter of 2.6 mm. There were no complications in any patient. Digital angiography is a useful method for laboratories devoted to coronary interventions for it allows confirmation of the severity of the stenosis, optimizes the balloon/artery relation, monitors partial results and measures the residual stenosis as well as the final diameter.


[Fetal atrioventricular block].

[Fetal atrioventricular block]. To study the pathogenesis, evolution and prognosis of the complete heart block of the fetus. Bidimensional echocardiography associated to M-mode and doppler was performed in 600 patients. All cases of congenital heart block were referred because the fetuses presented hydrops, bradycardia and/or cardiac malformation suspected by routine ultrasound. Isolated heart block was found in 6 fetuses (5 cases of complete type and 1 case of 2nd degree type 2:1). Heart block associated with complex cardiac disease and left atrial isomerism was found in 6 fetuses with no survivors (5 cases of complete type and 1 case of 2nd degree type 2:1). Heart block associated with atrioventricular discordante was found in 1 case. The findings of this study agree the literature about the relation between maternal anti-RO antibodies and isolated complete heart block. We also found a poor prognosis in the group with heart block and complex cardiac malformations.


[The effect of intravenous furosemide on the hemodynamic parameters and colloid osmotic pressure in patients with pulmonary edema]. To evaluate the effects of intravenous furosemide over hemodynamics variables and colloid osmotic pressure in patients with pulmonary edema. Eight patients with pulmonary edema, mean age of 58.3 +/- 7.5 years, 6 men, were evaluated. Hemodynamic monitoring was performed by Swan-Ganz catheter in pulmonary artery to obtain RAP and PAWP, in mmHg, and HR, in bpm. Cardiac output (CO) was obtained by thermodilution method. Cardiac index (CI) in L/min/m2, and systolic index, in ml, arose from variables above. Mean arterial pressure (MAP), in mmHg, was obtained through catheterization of radial artery. patients were treated with 20 mg of intravenous furosemide, and hemodynamic variables were measured before and after 5, 15, 30, 60 and 120 minutes. COP was measured in Weil oncometer (IL 196) at same intervals. A significant reduction of RAP (p = 0.002) and PAWP (p < 0.0001), HR (p = 0.02), COP (p < 0.0001) and gradient between PAWP-COP (p < 0.0001) were observed. RAP and PAWP reduction was greater in the first five minutes and, otherwise, COP reduction was gradual in 120 min. PAWP-COP gradient initially positive, stayed negative during all study. MAP, CI, SI and SVR did not show statistical differences. Furosemide administration reduced RAP, PAWP, HR, COP and PAWP-COP gradient, probably by a redistribution of fluid excess in the interstitial to intravascular space, through changes in driving fluid forces, with predominance in colloid osmotic pressure, which reverse fluid from intravascular to interstitial observed in pulmonary edema.


[Prolonged mechanical ventilation following heart surgery]. To study the causes of difficulty or impossible weaning of cardiac surgical patients undergoing mechanical ventilation in the postoperative period and their outcome. Three hundred and forty three consecutive adult patients submitted to open heart surgery were retrospectively studied and classified in three groups: I--patients in mechanical ventilation more than 24 hours; II--patients in mechanical ventilation less than 24 hours and reintubated some time after this period; III--patients successfully extubated in the first 24 hours of ventilation. The authors were able to identify the following preoperative factors associated with prolonged postoperative ventilation: cardiac failure, pulmonary hypertension, smoking, chronic obstructive pulmonary disease and previous open heart surgery. Significant factors in the immediate postoperative period (1st 24 hours) were: atelectasis, low output syndrome, perioperative myocardial infarction, reoperation for excessive bleeding, pleural effusion and cardiac arrest. This group of patients had a significant increase in nosocomial pneumonia, multiple organ failure (MOF) and surgical mortality. Pre and postoperative factors were identified associated with prolonged mechanical ventilation in the postoperative period and responsible by significant morbidity as such pulmonary infection, MOF and increase in mortality.


[The absence of risk factors for coronary disease in Yanomami Indians and the influence of acculturation on arterial pressure]. To investigate the hypothesis that hypertension and coronary heart disease are "civilization diseases", analyzing the distribution of their antecedents in an Indian population and observing the influence of acculturation on blood pressure. Seven hundred and twenty-five Yanomami Indians of both sexes, ages above 14 years, inhabitants of eight villages in Roraima and Amazonas states were examined. Measures related to all classical coronary risk factors were carried out and urine samples were collected to measure electrolytes. None of the known coronary risk factors were found. The blood pressure levels were low and did not increase with increasing age. There was influence of acculturation on blood pressure and it was in part mediated by increase in body weight and sodium intake. The absence of hypertension and other coronary risk factors and the increase of blood pressure with acculturation, among an isolated population, strongly suggest that these diseases are "civilization diseases".


[The Q wave in the electrocardiogram: necrosis or an electrically inactive area? Myocardial pseudoinfarct]. Six patients with Q-wave myocardial infarction in the ECG, two with coronary disease, two with metabolic alterations, one with acute myocarditis and another with ischemic stroke had an improvement of ECG tracings with disappearance of the Q wave. All had normal plasmatic levels of CPK and CKMB. It is believed that metabolic transitory disturbance of the myocardium increases the rest transmembrane potential turning the cell nonresponsive to electrical stimulus and without mechanical activity (inactive electrical zone, not a necrosis zone, which is an anatomo-pathological diagnosis).


[Dextrocardia in situs inversus totalis with obstructive coronary disease. Its treatment by coronary angioplasty by the brachial approach]. Dextrocardia in "situs inversus totalis" with obstructive coronary disease is a rare clinical situation, with few cases treated by coronary angioplasty using the femoral approach being reported. In this report we describe the case of a 61-year-old male patient who underwent successful dilatation of two arteries by the brachial approach. We discuss technical aspects related to the procedure, which may be easily performed when proper equipment is available.


[An evaluation of the efficacy and safety of pravastatin in patients with primary hypercholesterolemia. A Brazilian open multicenter study]. To evaluate the efficacy and safety of pravastatin in patients with primary hypercholesterolemia In an open-label multicenter uncontrolled study under the usual conditions of clinical practice 1,850 patients with primary hypercholesterolemia were submitted, after one month of placebo control and low fat/low cholesterol diet, to 12 weeks of treatment with pravastatin 10mg o.d. Significant reductions higher than 25% were obtained in plasma levels of total cholesterol and low density lipoprotein (LDL) cholesterol associated with an increase > 10% in the HDL cholesterol plasma concentration in 51% of the patients. The individual results were classified as satisfactory (higher than 20% decrease) in 70% of the studied population. The compliance of pravastatin was excellent, since 118 patients (6.4%) developed adverse reactions, but interruption of the treatment was necessary in only 18 (0.9%); 9 patients due to muscular pain, 3 by gastrointestinal symptoms, 2 by cutaneous reactions and 4 due to general complaints. The clinical conditions of diabetes, obesity, hypertension did not modify the efficacy of the drug. Previous unsatisfactory hypolipidemic treatment did not alter the results of the efficacy. The satisfactory results in efficacy and safety and the facility of the pravastatin use, make this drug as a first line agent in the hypolipidemic treatment.


Retinoic acid-induced neural tube defects with multiple canals in the chick: immunohistochemistry with monoclonal antibodies. When retinoic acid was injected into chicken yolks before incubation, various types of neural tube defect (NTD) were induced in 38-46% of the embryos after 48-96 h of incubation. The cranial NTD consisted of a delay in closing of the neural plate in 48-h embryos and some remained as disorganized, hyperplastic masses in older embryos. In spinal NTD of 48-h embryos the posterior neuropore remained widely open. In older embryos with a closed posterior neuropore, the neural tube appeared dissociated or disorganized locally at the trunk level. The tissue consisted of a dorsally-situated, neural-plate-like structure and a ventrally-located cell mass containing multiple canals. Although the location was different, this arrangement was similar to the overlap zone which appears between primary and secondary neurulation in normal development. Immunohistochemistry was performed using monoclonal antibodies which selectively stained various components of chick tissue. Considering the similarity in neural tube formation between chick and human, this experimental NTD may provide clues to understanding the etiology of human myelomeningocele.


Comparison of amplitude of human soleus H-reflex during sitting and standing. The modulation of the H-reflex in the human soleus muscle under conditions of different length or of background EMG activity was compared in 7 healthy subjects under three conditions: sitting, standing with support, and standing without support. The amplitude of the H-reflex increased when the muscle was shortened in both the sitting and standing conditions. The degree of increase in H-reflex was smaller during standing than sitting for the same change in muscle length. The H-reflex was augmented according to the increase of the background EMG. The "reflex gain", the ratio of the increase in amplitude of the H-reflex to soleus muscle EMG activity, decreased on sitting, standing with support and standing without support, ranked in that order. From these observations, it is concluded that the H-reflex is modulated by both muscle length and the degree of postural stability. The modulation of the reflex could be interpreted in terms of gain compensation and would serve to stabilize posture. A decrease in reflex gain may be appropriate in stabilizing the spinal reflex feedback loop during standing, especially without support.


Functional roles of the lateral suprasylvian cortex in ocular near response in the cat. The lateral suprasylvian (LS) area, an extrastriate visual area in the cat, has been suggested to play an important role in processing motion in 3-dimensional visual space. In addition, the LS area is related to all three components of the ocular near response, i.e. lens accommodation, pupillary constriction, and ocular convergence: microstimulation in this area evoked these intra- and extraocular movements, and neuronal discharges associated with these movements were also found. Anatomical pathways, direct and indirect, from this area to premotor nuclei in the brainstem are known to exist. The present paper reviews studies useful for assessing the functional roles played by the LS area in triggering and modulating component movements in the ocular near response.


CTF4 (CHL15) mutants exhibit defective DNA metabolism in the yeast Saccharomyces cerevisiae. We have analyzed the CTF4 (CHL15) gene, earlier identified in two screens for yeast mutants with increased rates of mitotic loss of chromosome III and artificial circular and linear chromosomes. Analysis of the segregation properties of circular minichromosomes and chromosome fragments indicated that sister chromatid loss (1:0 segregation) is the predominant mode of chromosome destabilization in ctf4 mutants, though nondisjunction events (2:0 segregation) also occur at an increased rate. Both inter- and intrachromosomal mitotic recombination levels are elevated in ctf4 mutants, whereas spontaneous mutation to canavanine resistance was not elevated. A genomic clone of CTF4 was isolated and used to map its physical and genetic positions on chromosome XVI. Nucleotide sequence analysis of CTF4 revealed a 2.8-kb open reading frame with a 105-kDa predicted protein sequence. The CTF4 DNA sequence is identical to that of POB1, characterized as a gene encoding a protein that associates in vitro with DNA polymerase alpha. At the N-terminal region of the protein sequence, zinc finger motifs which define potential DNA-binding domains were found. The C-terminal region of the predicted protein displayed similarity to sequences of regulatory proteins known as the helix-loop-helix proteins. Data on the effects of a frameshift mutation suggest that the helix-loop-helix domain is essential for CTF4 function. Analysis of sequences upstream of the CTF4 open reading frame revealed the presence of a hexamer element, ACGCGT, a sequence associated with many DNA metabolism genes in budding yeasts. Disruption of the coding sequence of CTF4 did not result in inviability, indicating that the CTF4 gene is nonessential for mitotic cell division. However, ctf4 mutants exhibit an accumulation of large budded cells with the nucleus in the neck. ctf4 rad52 double mutants grew very slowly and produced extremely high levels (50%) of inviable cell division products compared with either single mutant alone, which is consistent with a role for CTF4 in DNA metabolism.


A clinical trial of the effectiveness of water as a conductive medium in electrocardiography. A clinical trial was conducted in three hospitals to determine if common tap water is suitable for use as a conductive medium in electrocardiography (ECG). It compares two consecutive ECG recordings of 100 patients, the first recordings were obtained with water as the conductive medium, the second tracings used the electroconductive gel Redux Creme. Analysis involved comparison of the height of the R wave in lead V4 and tracing reports from a cardiologist 'blind' to the medium used. Results indicated that there was no statistically significant difference in the conductive ability of the two media. Analysis of the clinical performance of the media indicated that in 82% of the traces water was equal to or better than gel in clarity, and in 90% of traces water was equal to or better than gel in suitability for diagnosis. One implication of the study is the possibility of significantly reducing the cost of ECG procedures while ensuring the quality of tracings remains at a clinically acceptable level.


Development of an instrument to study the sexual relationship of partners during pregnancy. The development of an objective self-report instrument designed to identify the domain of sexual behaviours during pregnancy is described. The Pregnancy and Sexuality Questionnaire (PSQ) is concerned with sexual interest and arousal and with specific sexual behaviours of partners in a stable heterosexual relationship. Data were obtained two weeks apart from 15 couples presenting to an antenatal class and from two additional females whose partners did not participate. The validity and reliability of the PSQ are considered with particular emphasis on test-retest reliability. The results in general support the reliability of the instrument. The questionable reliability of some items is attributed to the natural sequence of change in sexual behaviours during pregnancy and to the relatively small sample size used. The PSQ appears to be sufficiently robust to be confidently applied both in sexual behaviour research and as an adjunct to clinical practice.


Strategies for reduction of noise levels in ICUs. This paper reports on a study of noise levels in an intensive care unit. The various noise sources and their sound levels were identified. Sources of noise were classified into those generated by: people, equipment and room furniture. Strategies for the reduction of noise to levels likely to be less disturbing to patients are discussed.


The decline of myths and myopia? The use and abuse of nursing history. Since 1980 a 'new' history of nursing has been emerging, one that attempts to address serious problems within nursing historiography such as the subordination of nursing history to medical history. There is a need for nurses to reject the narrow celebratory narratives produced by typical amateur medical historians. While problems of 'outsiders' writing the history of professions have been highlighted, problems inherent in the production of their own history by 'insiders' have been overlooked. A critical approach to the history of nursing will display different qualities and emphases to most previous writing in this field.


Exercise intolerance in patients with McArdle's disease or mitochondrial myopathies. To assess respiratory and metabolic adaptations in patients with phosphorylase deficiency and mitochondrial myopathies using maximal exercise tests. Five patients with McArdle's disease and five patients with mitochondrial myopathies performed the same incremental maximal exercise test. Their respiratory gas exchanges and the variation of the venous blood metabolites--lactate (LACT), pyruvate (PYR), alanine (ALA), ammonia (NH3)--were studied in comparison with the results of fourteen control subjects who performed the same test. Compared with controls, the two groups of patients displayed a similar significant decrease of their maximal VO2. In McArdle's patients the limitation of the maximal oxygen consumption was associated with a low respiratory exchange ratio (RER), a high VE/VO2, and characteristic metabolic data: no rise of LACT and PYR, a decrease of ALA and an important rise of NH3. In mitochondrial myopathies low VO2 max were due to a leftwards shift, i.e. towards low powers of exercise, of LACT, PYR, NH3 and ALA values. However the pattern of increase of LACT, PYR and NH3, exponential, and of ALA, linear, as well as respiratory exchange ratios were similar to control values. In this case, the limitation of oxygen consumption was due to a lack of the usual substrate, pyruvate. Low respiratory exchange ratio demonstrated that the muscle metabolism had a tendency to shift to lipid oxidation. These results suggest that patients with McArdle's disease may improve their muscle energy production by endurance training which enhances lipid metabolism, whereas in mitochondrial myopathies, the energy production by oxidation of pyruvate or lipids may be improved only by enzymatic substitution.


RNs as teachers of junior doctors.

RNs as teachers of junior doctors. Interviews with registered nurses and with interns were part of a preliminary study that explored the question of whether, because of the close working relationships between junior doctors and registered nurses on the wards, the latter might in fact play an important role in educating and supervising the former. Results of the study provide support for the hypothesis that nurses do play a role in teaching interns clinical procedures and in inducing them into ward routines and aspects of patient care. However, this teaching function is officially unacknowledged. It appears to proceed within the confines of the 'doctor-nurse game' in that the teaching-learning relationship involves an inversion of power and authority that cannot be acknowledged by participants. One recommendation from the study is that if registered nurses play this teaching role they should receive training and recognition for it.


Non-invasive identification of severe coronary artery disease in patients with long-standing diabetes mellitus. To detect severe coronary artery disease in asymptomatic middle-aged diabetic patients exposed to coronary artery disease risk factors. Forty-four middle-aged patients (30 to 65 years of age) with a known duration of diabetes exceeding 10 years and at least one additional cardiovascular risk factor were studied. Patients were free of anginal chest pain and had a normal 12-lead ECG at rest. All patients underwent 24-hour ambulatory ECG, maximal bicycle exercise electrocardiography and intravenous dipyridamole thallium myocardial scintigraphy. If one of these 3 non-invasive tests revealed signs of myocardial ischaemia, a coronary angiography was performed. Non-invasive investigation yielded the diagnosis of myocardial ischaemia in 9/44 patients (20%). Six of the 9 patients had significant coronary artery stenoses (> 70% narrowing) and 5 exhibited severe triple-vessel disease. With dipyridamole thallium scintigraphy, the positive predictive value for diagnosis of coronary artery disease was optimal. In diabetic patients with additional coronary risk factors, periodical thorough clinical examination and resting ECG may fail to detect severe coronary disease. More sophisticated cardiovascular non-invasive tests should then be proposed as part of the periodical care of these patients.


Acute and chronic effects of low dose almitrine bismesylate in the treatment of chronic bronchitis and emphysema. Study of the acute and chronic effects of low-dose almitrine therapy in stable hypoxaemic patients with chronic bronchitis and emphysema. A low daily dose of 75 mg almitrine bismesylate was administered for six months in 23 patients with chronic bronchitis and emphysema. Nine patients (group 1) were placed on oral almitrine bismesylate 25 mg t.i.d. after they had received a single intravenous dose of 60 mg almitrine three months earlier. Fourteen additional patients, seven receiving almitrine (group 2) and seven placebo (group 3) were randomized for a 6 month double-blind evaluation of both acute and chronic effects of 75 mg almitrine on pulmonary gas exchange and on pulmonary haemodynamics. All patients were followed-up with regular measurements of blood gases, body plethysmography and with evaluation of peripheral nerve function. Acute effects of almitrine were a significant increase in arterial oxygen tension by 14 mmHg after intravenous (p < 0.001) and by 15 mmHg after oral administration (p < 0.001), amelioration of hypercapnia, a slight transient increase in mean pulmonary artery pressure from 26 +/- 7 to 29 +/- 6 mmHg (NS) and a decrease of shunt due to improvement in ventilation/perfusion mismatching. In contrast, no acute changes in blood gases and pulmonary pressures were seen in the placebo group. A combination of almitrine with oxygen (8-10 L/min) was most effective in amelioration of hypoxaemia and shunt. With chronic almitrine therapy, the improvements in gas exchange persisted without elevation of pulmonary artery pressure (26 +/- 8 mmHg), whereas a negative trend in change of blood gases and pulmonary artery pressure occurred in the placebo treated group (NS). No significant changes in external ventilation, other spirometric parameters or adverse effects concerning peripheral nerve function were seen after almitrine or placebo treatment. The elimination of almitrine was fitted to a three compartment model and the terminal half-life in the patient population was found to be 32 +/- 29 days after intravenous dosing. Acute and six-month almitrine bismesylate therapy at a low daily dose of 75 mg is found to be safe, even in severely compromised patients, with regard to pulmonary haemodynamics and peripheral nerve function. The agent is beneficial to pulmonary gas exchange, with reduction of hypercapnia, of intrapulmonary shunt and also with regard to sustained elevation of arterial oxygen tension. A combination with inhaled oxygen seems especially efficacious.


Level-dependent inhibitory effect of hyperaluminaemia on parathyroid hormone secretion in patients with end-stage renal failure. Serum aluminium and parathyroid hormone levels were measured in chronic dialysis patients at discovery of accidental exposure to high dialysate aluminium levels and followed after adequate water purification. Twenty-nine patients with chronic renal failure on maintenance haemodialysis were accidently exposed to dialysate aluminium levels of 65 micrograms/L (recommended Food and Drug Administration values less than 10 micrograms/L) for 18 months. At discovery, oral aluminium was withdrawn and dialysate aluminium levels were corrected to less than 5 micrograms/L. Serum aluminium, parathyroid hormone, calcium, phosphorus and alkaline phosphatase levels were determined at discovery and two months and one year after the corrective measures. Mean serum aluminium level was 167.6 +/- 15 micrograms/L at discovery and simultaneous serum parathyroid levels were 7.9 +/- 2.2 pmol/L (normal values 1.1 to 4.6 pmol/L). Two months after discontinuation of oral aluminium and correction of dialysate aluminium levels to less than 5 micrograms/L, the patients' mean serum aluminium dropped to 49.6 +/- 4.3 micrograms/L and simultaneous serum parathyroid hormone levels rose to 14.6 +/- 3.2-pmol/L (p < 0.001). Similar levels were maintained at one year. Serum calcium did not change significantly. There was a significant correlation between the drop in serum aluminium and the increase in parathyroid hormone. These results confirm animal experiments and show convincingly that aluminium inhibits parathyroid secretion also in humans.


Papillomaviruses in human disease: Part II. Molecular biology and immunology of papillomavirus infections and carcinogenesis. As summarized in the last issue of the EJM, human papillomaviruses induce a great variety of neoplastic lesions of mucosal epithelia and the skin. Particular types of these viruses are associated with specific human cancers, most notably anogenital carcinomas. These tumours account for about fifteen percent of the whole worldwide cancer burden. However, recent epidemiological studies revealed that papillomavirus infections including those with the cancer-related papillomavirus types are very widespread even among asymptomatic healthy individuals. Here, the current understanding of the molecular events leading to papillomavirus-induced tumours will be reviewed. It is assumed that these tumours arise as a consequence of several molecular modifications of persistently papillomavirus-infected epithelial cells. Experimental studies revealed that the virus types associated with anogenital cancers harbour two potential oncogenes referred to as E6 and E7. These viral genes are consistently expressed in HPV-associated anogenital carcinoma cells. HPV-associated cervical carcinoma cells loose their neoplastic growth properties if the expression of the E6 and E7 genes is inhibited. The proteins encoded by these viral genes thus appear to be ideal targets for a specific pharmacological approach to treat papillomavirus associated cancers or their respective precursor lesions. Recent studies in animals furthermore suggest that active vaccination with the viral oncoprotein E7 prevents growth of papillomavirus associated tumours. Hence, the possibility arises that also in man, vaccination with the viral transforming proteins might prevent the development of papillomavirus associated cancers.


Cardiovocal (Ortner's) syndrome left recurrent laryngeal nerve palsy associated with cardiovascular disease. Five patients with cardiovascular disease presented with hoarseness due to left recurrent laryngeal nerve palsy. One had secundum atrial septal defect, one had ventricular septal defect, two had mitral stenosis and the other had aortic aneurysm. All except the patient with aortic aneurysm had pulmonary artery dilatation and moderate to severe pulmonary hypertension. Four patients' hoarseness resolved after successful interventional therapy. As for the patient with the aortic aneurysm, hoarseness persisted; the patient died before surgery. We postulate that the dilated pulmonary artery or aortic arch was responsible for the compression of the left recurrent laryngeal nerve.


Mycobacterial infections following heart valve replacement. Mycobacterial infection is an uncommon but very serious complication of heart valve replacement and other forms of cardiac surgery. Tuberculosis has been a rare complication of valve replacement in the industrially developed countries owing to the low incidence of that disease in such countries. Most reported cases are associated with the insertion of human allograft valves. Valvular tuberculosis could become a more serious problem if heart valve replacement surgery is used to any extent in countries where tuberculosis is common. The majority of other mycobacterial infections occurring after heart surgery have, for unknown reasons, been due to the rapid growers M. chelonae and M. fortuitum. Porcine xenograft valves have been contaminated by M. chelonae, possibly during manufacture as this is not a natural pathogen of pigs. A minority of patients receiving valves known to be contaminated by M. chelonae subsequently developed valve disease. Mycobacterial disease following insertion of mechanical valves is a very uncommon occurrence but the prognosis is poor. There have been several outbreaks of infection of the sternotomy wound by M. chelonae and M. fortuitum and, although the prognosis is better than for mycobacterial endocarditis, treatment, especially for infections due to M. chelonae, often involves extensive debridement including removal of the entire sternum. In view of the poor response to therapy, prevention by avoidance of contamination of all surgical materials, including implanted valves, by environmental mycobacteria is of paramount importance.


In vitro calcification of bioprosthetic heart valves: report of a novel method and review of the biochemical factors involved. The lifetime of bioprosthetic heart valves is limited by primary tissue failure and calcification of the valve leaflets. There are indications that synthetic elastomeric materials may also be subject to this problem. The mechanism of calcification is not known, but it is of interest that calcification can be induced in tissue even in the absence of cellular mechanisms, outside the body. Many hypotheses relate to inhibitory or promotory factors rather than primary instigators of calcification and none has led to a satisfactory solution of the problem. The study of calcification in replacement valves generally utilises in vivo test methods i.e. complex biologic systems. This creates difficulty in defining the primary factors involved. The use of in vitro test methods, including a novel fatigue tester method, has been reviewed. Various test media have been used, including simple salt solutions (allowing definition and controlled modification of the calcification medium) and bovine plasma. Comparison of static and dynamic in vitro methods with the rat subcutaneous implant model indicated a lower degree of calcification in vitro: the calcification achieved was, however, significantly greater than similar material not subject to calcification processes. Dynamic in vitro tests produced greater calcification than static in vitro tests. Porcine aortic valve material, in static tests, behaved similarly to bovine pericardium. In vitro calcification testing has a useful role to play in the economic screening of new materials or modifications of existing materials prior to in vivo testing. It may also aid the definition of the mechanism of calcification and hence the development of solutions to the problem.


Cavitation of mechanical heart valves under physiologic conditions. Cavitation has recently entered the discussion of factors leading to blood and material damage after implantation of mechanical heart valves. Since direct evidence for this phenomenon cannot yet be demonstrated in vivo, an in vitro method had to be developed to permit the investigation whether cavitation actually occurs under (simulated) physiologic conditions and to clarify its clinical relevance. Previous studies have shown that different types of commercially available mechanical valves exhibit different tendencies to generate cavitation in vitro. The present study presents a test protocol for the assessment of cavitation generated by different replacement valves under simulated physiologic conditions. Comparative investigations were performed in order to transfer the in vitro results in vivo conditions. Although mechanical valves with an overlapping closing body/valve ring configuration tend to create cavitation earlier, cavitation could not be demonstrated for any investigated mechanical valve type under simulated resting conditions. The danger of continuous cavitation damage is therefore low. Certain valve types exhibit cavitation only at higher heart rates (more than 120-140 beats/min). Some valve types do not show cavitation even during heavy exercise. Based on mathematical models and experimental investigations, it is very likely that if cavitation does occur, blood and material damage may be expected.


Reoperations on cardiac valves.

Reoperations on cardiac valves. As the number of patients undergoing cardiac valve replacement has grown, valve reoperations have become increasingly frequent. The newer generations of mechanical valves are far more efficient and freer from structural failure than the older ones. However, other valve and non-valve related complications still constitute a major cause of morbidity and mortality. On the other hand, bioprostheses, implanted in large numbers in the 1970's and early 1980's, have now gone into the second decade of life since implantation, when biodegradation becomes more frequent. Reoperations are technically more demanding than the original valve procedures because of the mediastinal and pericardial adhesions and the condition of the anulus after removal of the previous prosthesis. Greater awareness of the most dangerous steps and refinements to surgical technique have contributed to the decreased mortality observed in recent years. The risk is higher in certain conditions, such as the presence of prosthetic valve endocarditis and the patient being operated on an emergency basis in NYHA functional class IV. It may also be increased in females and the elderly. Multiple reoperations also carry a higher risk in most surgeon's experience. However, elective reoperations for defective mechanical valves and for replacement of a previously repaired mitral valve carry similar mortality rates to primary valve replacement procedures. The global mortality rates have not been significantly higher in the hands of experienced surgeons working in centers where reoperations are performed frequently. In smaller series high mortality rates are a constant, which underscores the importance of the learning curve. The indications for reoperation must therefore consider all risk factors and, when possible, the procedure must be performed by those who have the most experience. Under these circumstances, elective re-replacement of degenerating bioprostheses and of defective mechanical valves in asymptomatic patients may be advisable.


Recommendations for prophylactic removal of heart valve prostheses. Should elective, prophylactic reoperation for removal ("recall") of a well-functioning mechanical heart valve, such as a 60 degree or 70 degree Convexo-Concave Bjork-Shiley prosthesis, be recommended to healthy, active patients, to prevent rare catastrophic valve failure (strut fracture)? Making such a recommendation inherently is tough because the risk of strut fracture is low, a heart reoperation is required, and the new replacement device might have problems of its own. The recommendation is made tougher by the lack of multivariable analyses of survival with and without "recall," including patient and manufacturing variables, that would permit desirable selective "recall" on the basis of direct patient-specific predictions and comparisons. We present available informative substitute multivariable equations that are combined to predict patient-specific survival without "recall". We propose that a multivariable equation for first-time valve replacement is an appropriate substitute for predicting the risk of "recall." Using these equations, survival and length of life risks and benefits of "recall", and their degree of uncertainty, are presented for older and younger patients using both realistic, although worst-case, assumptions and ones maximally favorable to "recall." From these analyses we would not at this time, in general, advise "recall" of 60 degrees-70 degrees Convexo-Concave Bjork-Shiley valves. Recommendations for a specific patient would need to be guided by patient-specific comparisons.


Quality of life after heart valve replacement. Over the last three decades, heart valve replacement has become a safe and routine surgical procedure, but replacement devices are still far from ideal. Despite improvements in materials and design, life-long anticoagulation remains mandatory for mechanical valves. The major shortcoming of the less thrombogenic bioprosthetic valves is early tissue failure. Parallel to the decrease in operative mortality after heart valve replacement, the potential quality of life for survivors has been becoming increasingly important in evaluating the late results and in selecting the appropriate device for the given patient. All factors that determine the quality of life are strongly affected by the operation due to the usually dramatic improvement both in subjective status and objective parameters postoperatively. The patient, thus, can return to normal activities, maintain self-esteem and keep normal relationships at work, in the community and at home. Psychoneurologic dysfunction was also found to decrease greatly within six months, although more than a quarter of patients were depressed preoperatively because of their disease. Overall, the experience was generally satisfying.


Outcomes management in heart valve replacement surgery: early experience. Recent efforts at reducing health care expenditures and practice variations have focused attention on treatment appropriateness, patient preference, and quality of life as important elements of treatment evaluation. These characteristics of medical treatment can be assessed by administration of a structured, valid health status assessment questionnaire before and at fixed intervals following treatment, and standardized scores may be compared to normal scores derived from healthy, untreated populations. One hundred valve replacement patients completed a standardized questionnaire, the 'SF-36', preoperatively and at 1- and 6-months postoperatively. Preoperatively, valve replacement patients are substantially impaired in their physical capacity, their ability to function in important roles, and their vitality. At one month, they report significant decrements in social and role functioning and in pain which we attribute to the trauma of surgery and recovery. At six months, mean scores approximate those for sex- and age-matched normals except for persistent moderate impairment in role functioning. Post-operative functional impairment is greatest for those undergoing mitral valve replacement, particularly when coronary artery grafts are performed concurrently, and for patients receiving bioprosthetic valves. Structured health status assessment provides a useful adjunct to other methods of assessing clinical status and evaluating treatment outcomes.


Influence of different pressure gradients on late clinical outcome after aortic valve replacement. Late outcome vs. hemodynamic parameters were assessed and compared in a series of 44 patients followed for 10-17 years after aortic valve replacement either with a Starr-Edwards A 1260 (SE) or a Bjork-Shiley 60 degrees (BS) prosthesis. The two groups, 22 patients each, were selected by computer from the data base SG as to be matched for age, sex, underlying lesion, date of implantation, valve size, left ventricular function, and concomitant coronary artery disease. There was no significant difference in mortality and complication rates. Clinical evaluation at a mean of 12.5 +/- 2.2 years postoperatively revealed identical findings of heart size on chest X-rays (CTR 0.50 +/- 0.04 SE vs. 0.50 +/- 0.05 BS) and nearly identical incidence of left ventricular hypertrophy on the ECG (2/22 SE and 1/22 BS). There was a statistically significant difference in Doppler ultrasonic peak pressure gradients between the two valve types (SE 32 +/- 15 mmHg, BS 23 +/- 9 mmHg; p = 0.047), and of fractional shortening on M-mode echocardiograms (SE 30 +/- 9%, BS 37 +/- 8%, p = 0.038), but this was not reflected by a difference in the symptomatic status of the two groups. It is concluded, that in two groups of patients surviving 10-17 years after isolated aortic valve replacement with SE or BS valves, the statistically significant nine mmHg difference in gradient across the two valve types had no effect on long-term clinical outcome.


Changes in valvular resistance, power dissipation and myocardial reserve with aortic valvuloplasty. Balloon aortic valvuloplasty results in small changes in valve area with great symptomatic improvement in some patients, while others have little relief with greater increases in valve area. Alternative indices to valve area may help explain this clinical discrepancy. A calculation of valve area does not provide a means of assessing the load imposed by a stenotic valve, while the complementary index valve resistance, defined as the quotient of mean pressure difference divided by flow, allows many other hemodynamic calculations and may provide an additional measure of the hemodynamic importance of valvular obstructions. To assess the value of these calculations, we studied hemodynamic changes in thirty elderly patients undergoing valvuloplasty for aortic stenosis. The valve area, as calculated by the Gorlin formula, increased by an average 67% (0.59 cm2 to 0.95 cm2), while hemodynamic resistance decreased by an average 52% (453 to 207 dyne.sec.cm5). The values of resistance were used to predict pressure gradients and work loads at different cardiac outputs. The increase in myocardial reserve with valvuloplasty was calculated as the increase in cardiac output that could be achieved at the pre-valvuloplasty value of either total ventricular pressure or ventricular work. These calculations assumed that valvular resistance did not change with cardiac output and that peripheral resistance varied inversely to cardiac output so as to maintain a constant aortic (systemic) pressure. The increase in myocardial reserve was 18% when ventricular work rate was the limiting factor, and 103% when pressure was limiting. The increase in reserve may be closer to the higher value since the myocardial work rate is probably not limited by myocardial energy in the absence of coronary artery disease. Four patients who did not do well clinically were characterized by small increases in reserve, either because of inadequate dilatation of the valve or because the original stenosis was not severe. Valve resistance, myocardial reserve, and ventricular work may be calculated using standard hemodynamic measurements. In conjunction with aortic valve area, these indices provide significant complimentary information and may further elucidate the hemodynamic consequences of valvular obstruction.


Serial changes of mitral flow pattern after percutaneous transvenous mitral commissurotomy--assessment of Doppler and two-dimensional echocardiography. To evaluate the acute change in the mitral flow pattern, especially pressure half-time after percutaneous transvenous mitral commissurotomy (PTMC) and to investigate the factors influencing the mitral flow pattern, Doppler and two-dimensional echocardiographic studies were performed in 15 patients before and two, six, 10 and 24 hours and seven days after PTMC. Mitral valve area increased and the mean mitral pressure gradient decreased after PTMC (1.0 +/- 0.4 cm2 to 1.8 +/- 0.4 cm2; 11 +/- 6 mmHg, to 3 +/- 2 mmHg, p < 0.01). Pressure half-time also decreased two hours after surgery, from 292 +/- 70 msec to 176 +/- 48 msec (p < 0.01) and then gradually decreased to 140 +/- 47 msec within seven days of the procedure without remarkable changes in mitral valve area and the mean transmitral pressure gradient. Left atrial dimensions decreased and left ventricular end-diastolic dimensions gradually increased after PTMC (51 +/- 6 mm to 46 +/- 5 mm; 47 +/- 4 mm to 50 +/- 3 mm). The time course of this was similar to that of the pressure half-time. Further study, in which the changes in pressure half-time were evaluated within 30 minutes of PTMC in 17 patients, indicated that pressure half-time significantly decreased from 248 +/- 69 msec to 139 +/- 28 msec five minutes after balloon inflation, slightly increasing again after 30 minutes to 153 +/- 31 msec.(ABSTRACT TRUNCATED AT 250 WORDS)


Late tricuspid regurgitation following mitral valve surgery. The development of late tricuspid regurgitation is an important complication of mitral valve surgery, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined, but it is usually attributable to a functional abnormality of the tricuspid valve. Whilst its development may indicate an increased afterload on the right heart as a consequence of persistent pulmonary hypertension, mitral prosthetic dysfunction, progressive aortic valve disease or left ventricular failure, late tricuspid regurgitation may also develop in the absence of these factors and then may reflect right ventricular dysfunction and/or a localized abnormality of the tricuspid anulus. Failure to recognize and correct tricuspid regurgitation at the time of initial surgery may also account for many cases of tricuspid regurgitation but its re-appearance following tricuspid annuloplasty is uncommon and usually reflects a failure of the mitral prosthesis. A reduction in the prevalence of late tricuspid regurgitation is an important objective in view of the high operative mortality and disappointing long term results associated with reoperation for tricuspid regurgitation. This may be best achieved through combining earlier mitral valve surgery with the accurate detection and liberal correction of accompanying tricuspid incompetence at the time of initial surgery.(ABSTRACT TRUNCATED AT 250 WORDS)


Structural valve deterioration in elderly patient populations with the Carpentier-Edwards standard and supra-annular porcine bioprostheses: a comparative study. From 1975 to 1989, over 1400 patients in the elderly population and over 1700 patients under 65 years of age received the Carpentier-Edwards standard (CE-Standard) and supra-annular porcine (CE-SAV) bioprotheses. The mean ages of the patients receiving the two protheses within the three subgroups of the elderly population-65-69 years, 70-79 years, and 80 years and over-were relatively similar. There was no statistically significant difference in the performance of the prostheses regarding structural valve deterioration (SVD) at seven years. The freedom from SVD for aortic valve replacement in the 65-69 years group at seven years was 98.7% +/- 1.3% for the CE-Standard and 98.7% +/- 1.0% for the CE-SAV, for both the 70-79 years group and the 80 years and over group the figure was 100% for both prostheses (p = NS). The freedom from SVD after mitral valve replacement in the 65-69 years group at seven years was 90.0% +/- 4.3% for the CE-Standard and 84.8% +/- 7.5% for the CE-SAV, for the 70-79 years group it was 95.3% +/- 3.2% and 95.5% +/- 3.6% respectively and for the 80 years and over group the figure was 100% for both prostheses (p = NS within groups). The long term freedom from SVD after aortic valve replacement was 98.4% +/- 3% at 15 years for the CE-Standard in the 65-69 years group, 94.9% +/- 5% at 13 years for the 70-79 years group and 100% at 13 years for the 80 years and over group.(ABSTRACT TRUNCATED AT 250 WORDS)


Chronic rheumatic heart disease in India: a reappraisal of pathologic changes. Rheumatic heart disease contributes to significant cardiac morbidity and mortality in India. The disease predominantly affects the valvular endocardium culminating in crippling valvular deformities, preferentially involving the mitral valve which may be severely affected in children and young adults. This appears to be unique to India and has been termed juvenile mitral stenosis. It is characterized by cardiomegaly, refractory congestive heart failure, and marked by elevated pulmonary vascular pressures and a progressive, fulminant clinical course. Autopsies of patients dying of rheumatic heart disease revealed that the mitral valve was most commonly afflicted either alone or in combination with the aortic and tricuspid valves in 31.6% and 52.8%, respectively. Organic involvement of the tricuspid valve was documented in 38.4% of cases. The extent and severity of the disease process was most marked in the mitral valve, followed by the aortic and tricuspid valves. Mitral valves showed various degrees of calcification, moderate or severe calcification being observed in 36.4%. Chronic inflammatory cell infiltration was observed in both calcified and non-calcified valves. The phenotypic profile of the inflammatory cells by immunohistochemical staining revealed a significant number to be T-helper/inducer lymphocytes. Lungs from cases of mitral stenosis exhibited prominent vascular and parenchymal changes. Pulmonary vessels revealed moderate to marked medial hypertrophy of the medium sized branches of the pulmonary artery. Dilatation lesions were also seen in a few cases. The most striking parenchymal change was the prominent smooth muscle in the bronchoalveolar walls. The extent and severity of the vascular and parenchymal changes were more marked in juvenile patients. The presence of inflammatory cells in cases of chronic heart disease reflects a possible ongoing insult/injury to some persistent antigenic stimulus by beta hemolytic streptococcal antigens that have primed the various target tissues. Further study of surface characteristics of various mesenchymal cells may help in understanding the nature and pathogenesis of this serious cardiac problem.


Tumour necrosis factor mediates the survival benefit of interleukin 2 in a murine pulmonary metastases model. Antibody to tumour necrosis factor (TNF Ab) markedly decreases the toxicity of systemic interleukin-2 (IL-2) in mice but does not completely abrogate the anti-tumour response in terms of number of pulmonary metastases. Experiments were performed with a murine model of pulmonary metastases treated with high-dose IL-2 and concomitant TNF Ab or control antibody (CON Ab) to determine the effects of TNF Ab on survival. Mice were given either equal doses of IL-2 and TNF Ab or CON Ab or equitoxic doses of IL-2. In four consecutive experiments mice given TNF Ab tolerated 5 to 6 additional IL-2 doses (a 40-60% increase in total doses) in the equitoxic IL-2 dose group compared to the maximally tolerated dose with CON Ab. In all four experiments TNF Ab-treated mice had decreased survival compared to the CON Ab group given equal doses of IL-2 and in two of four experiments this difference was statistically significant (P2 < 0.01). Mice given 40-60% additional doses of IL-2 with TNF Ab had no improvement in survival compared with equitoxic doses of IL-2 with CON Ab in three of four experiments (P2 = 0.32, P2 = 0.67, P2 = 0.69). The TNF Ab preparation had no direct inhibition of IL-2 activity in an in vitro IL-2 proliferation bioassay. TNF Ab consistently blocks IL-2 toxicity and it also abrogates IL-2 therapeutic efficacy such that survival parallels treatment toxicity in this experimental model.


Management of neutropenic colitis.

Management of neutropenic colitis. Neutropenic colitis is recognized as a rare complication of chemotherapy in haematological malignancies. By contrast, the complication is less well known in relationship to chemotherapy for solid malignancies. There are very few examples reported and this paper adds three further cases and reviews the literature. We emphasize that although some cases of neutropenic colitis may be managed medically, full thickness involvement of the bowel wall may lead to perforation and require surgery. The pathogenesis of this progression is discussed and it is concluded that clinical awareness is important in the diagnosis. The signs of peritonitis or septicaemia are indications for excisional surgery with the formation of a temporary ileostomy.