123rc/medical_text huggingface dataset:
Mechanical cardiopulmonary support for refractory cardiogenic shock. From February 1982 to February 1990, 38 patients (30 male patients and 8 female patients) ranging in age from 10 to 78 years (mean 49.4 years) have been supported with arteriovenous extracorporeal membrane oxygenation (ECMO) at St. Louis University Medical Center as a resuscitative system for cardiac arrest or cardiogenic shock. All patients were unresponsive to conventional resuscitative measures including an intraaortic balloon pump in 25 patients. Patients were resuscitated in the intensive care unit, cardiac catheterization laboratory, or the emergency department. Diagnosis varied from acute myocardial infarctions (12 patients), ischemic disease (15 patients), end-stage cardiomyopathy (7 patients), congenital heart disease (3 patients), or postoperative cardiac transplant graft rejection (1 patient). Three patients could not be resuscitated with ECMO because of low flow, but the remaining 35 (92%) achieved hemodynamic stability with ECMO flows greater than 2 L/min/m2. Duration of support ranged from 0.5 to 130 hours (mean 28 hours). Twenty-four patients were successfully weaned from ECMO support after coronary artery bypass (five patients), cardiac transplantation (two patients), or ventricular assist device insertion (eight patients), or with inotropic support (nine patients). Of the 14 patients not weaned, three were inadequately resuscitated, two had percutaneous transluminal coronary angioplasty while receiving ECMO, and nine were not candidates for further intervention. Nine (24%) patients were discharged and are long-term survivors. Our results indicate that resuscitative ECMO is useful for intervals of 12 to 24 hours and can best be applied with (1) patients younger than 60 years of age; (2) patients having acute events (failed percutaneous transluminal coronary angioplasty) amenable to surgical intervention; and (3) candidates for cardiac transplantation who could be switched to more sophisticated devices within 12 to 24 hours of ECMO insertion. With these criteria, ECMO, when used as a resuscitative system, can result in increased survival in selected patients with refractory cardiogenic shock or cardiac arrest.
Clear cell sarcomas and metastatic soft tissue melanomas. A flow cytometric comparison and prognostic implications. Eleven soft tissue clear cell sarcomas (CCS) were examined flow cytometrically for their DNA content with a correlation of the DNA with the patients' survival. Diploidy was expressed in six sarcomas and it conferred a longer survival (mean, 68.6 months) than aneuploid sarcomas (mean, 8.2 months). For comparison, 13 metastases to soft tissues from cutaneous melanomas were assessed by flow cytometric study. The aneuploid neoplasms of both entities were categorized into low and high degree based on extent of the DNA index (DI). Low degree was defined by a DI of less than or equal to 1.5 and high degree by a DI of greater than 1.5. Significant differences in DNA content between CCS and metastatic melanomas were observed. Melanomas were preponderantly aneuploid (11/13) of high degree (mean DI, 1.7) whereas CCS manifested more diploidy (six of 11) and their aneuploidy was of a low degree (mean DI, 1.2; P = 0.001). Clear cell sarcomas and melanomas were also examined for their immunoreactivity to S-100 protein and HMB-45 antigen. All CCS reacted with S-100 protein and HMB-45. In CCS the reactions were diffuse for both in six tumors, diffuse with HMB-45 and moderate to S-100 protein in three tumors and diffuse with S-100 and moderate with HMB-45 in two tumors. All melanomas reacted diffusely to S-100 protein except for one heavily pigmented tumor which reacted only focally. The reaction to HMB-45 was diffuse in nine and focal in three melanomas. These data suggest that measurements of DNA content in CCS may be valuable in predicting clinical outcome and that there are quantitative differences in DNA content between CCS and metastatic melanoma in soft tissues.
Effect of left ventricular aneurysm on risk of sudden and nonsudden cardiac death. Although left ventricular (LV) aneurysm is associated with increased mortality, its independent prognostic significance is controversial. To determine the effect of LV aneurysm on risk, 121 patients with healed myocardial infarction (MI), 55 manifesting akinesia on ventriculography (MI group) and 66 with LV aneurysm characterized by diastolic deformity (eccentricity) and systolic dyskinesia (LV aneurysm group) were studied. At a mean follow-up of 5.7 years, there were 32 cardiac deaths (12 MI vs 20 LV aneurysm), including 9 sudden deaths (1 MI vs 8 LV aneurysm). Multivariate analysis revealed decreasing ejection fraction to be the best predictor of total cardiac death, and revascularization to be protective. Nonsudden cardiac death was predicted by ejection fraction, absence of revascularization and right coronary artery disease, whereas sudden cardiac death was predicted by LV aneurysm and the frequency of ventricular ectopic complexes on Holter monitoring. In the MI group, ejection fraction was the only significant predictor of total cardiac death and nonsudden cardiac death. In the LV aneurysm group, total cardiac death, as well as nonsudden cardiac death, were predicted by ejection fraction, ventricular tachycardia and right coronary artery disease, whereas ventricular tachycardia predicted sudden cardiac death. It is concluded that the risk profile for total cardiac death differs between LV aneurysm and MI patients, and that LV aneurysm constitutes an independent predictor of late sudden cardiac death after MI. Moreover, on a substrate of LV aneurysm, the risk factors for sudden cardiac death and nonsudden cardiac death differ, with ventricular tachycardia being the sole predictor of sudden cardiac death. Furthermore, Holter monitoring is valuable in identifying patients at persistent risk of sudden cardiac death.
Replacement of the aortic valve or root with a pulmonary autograft in children. Between January 1967 and December 1988, 34 patients ranging in age from 3 to 18 years (mean, 14 +/- 3.6 years) underwent replacement of the aortic valve or root with their own pulmonary valve. The indication for operation was left ventricular outflow obstruction in 16 patients (47%), aortic regurgitation in 14 (41%), mixed aortic valve disease in 3 (9%), and failure of a previously implanted aortic homograft in 1 (3%). There were four early deaths, all before 1971, giving a hospital mortality of 11.8% (70% confidence interval, 6% to 20%). Surviving patients have been followed up a cumulative total of 214 patient-years, the longest period of observation being 16 years 8 months. Late mortality was 13.3% (70% confidence interval, 7% to 23%), and 4 other patients required removal of the pulmonary autograft for endocarditis. Actuarial rates at 16 years were 74% +/- 11% for freedom from reoperation on the left ventricular outflow tract, 80% +/- 10% for freedom from reoperation on the right ventricular outflow tract, and 77% +/- 10% for late survival. There was no instance of primary structural degeneration in the pulmonary autograft, and all surviving patients were in New York Heart Association functional class I without medication. This experience demonstrates that the pulmonary autograft can achieve good early and medium-term results in young patients. Should growth potential be realized, it might constitute the ideal biological valve for the left ventricular outflow in children.
The molecular biology of acute myeloid leukemia. Proto-oncogene expression and function in normal and neoplastic myeloid cells. Proto-oncogenes and suppressor genes fall into four functional groups: growth factors, growth factor and hormone receptors, signal transducers, and transcriptional regulatory factors. Many of these genes are selectively expressed in myeloid cells and may play a role in normal development of the myeloid lineages. Furthermore, chromosomal rearrangements, deletions, and mutations may disrupt the normal expression or function of these genes, promoting MPD and leukemogenesis. Many of the genes altered by karyotypic abnormalities in myeloid disorders are only beginning to be identified. Future studies undoubtedly will determine the molecular mechanisms whereby these genes, residing at karyotypic breakpoints in myeloid disorders, promote neoplastic transformation of myeloid cells.
Coexisting thymic carcinoid tumor and thymoma. Thymic carcinoid tumors are unusual neoplasms that are different from thymomas. We report a case of coexisting thymic carcinoid tumor and thymoma associated with myasthenia gravis. The clinicopathological findings are discussed with a review of the literature.
Effects of dipyridamole and aminophylline on hemodynamics, regional myocardial blood flow and thallium-201 washout in the setting of a critical coronary stenosis. Experiments were performed to characterize the interaction of intravenous dipyridamole and aminophylline on thallium-201 transport kinetics, regional myocardial blood flow and systemic hemodynamics in the presence of a critical coronary artery stenosis. In 12 dogs with a critical left anterior descending coronary artery stenosis, arterial pressure decreased from a mean value (+/- SEM) of 107 +/- 6 to 94 +/- 3 mm Hg (p less than 0.05) and distal left anterior descending artery pressure decreased from 70 +/- 7 to 55 +/- 4 mm Hg (p less than 0.05) after intravenous administration of dipyridamole (0.25 mg/kg body weight). In the left anterior descending perfusion zone, the endocardial/epicardial flow ratio decreased from 0.70 to 0.36 and the intrinsic thallium washout rate was significantly prolonged. Intravenous aminophylline (5 mg/kg) reversed the dipyridamole-induced systemic hypotension and transmural coronary steal and restored the thallium washout rate to baseline values. In six other dogs, aminophylline alone resulted in no alterations in systemic and coronary hemodynamics or regional myocardial blood flow. As expected, dipyridamole-induced vasodilation and coronary steal were prevented by aminophylline pretreatment. These data show that in a canine model of partial coronary stenosis, systemic hypotension, adverse regional flow effects (coronary steal) and prolonged thallium-201 washout consequent to intravenously administered dipyridamole are promptly reversed by intravenous aminophylline administration. Aminophylline alone had no significant hemodynamic and coronary flow effects. This study provides further insight into the altered thallium kinetics occurring as a consequence of dipyridamole-induced vasodilation and suggests that the prompt reversal of symptoms and signs of ischemia with aminophylline in patients receiving intravenous dipyridamole for clinical imaging studies probably reflects the reversal of transmural coronary steal.
NSAID-induced gastrointestinal damage. A critical review of prophylaxis and therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) cause acute diffuse injury to the gastroduodenal mucosa, and also cause chronic focal ulcers that may bleed or perforate without warning symptoms. Acute and chronic lesions are distinct, are pathogenetically different, respond differently to drugs, and require different management strategies. The principal rationale for antiulcer therapy in NSAID users is to prevent or reduce potentially fatal outcomes; to date no evaluated drug meets this criterion for efficacy. Antacids and H2-receptor antagonists, based on open uncontrolled studies, appear to heal both gastric and duodenal ulcers, and maintain them healed during continued NSAID use; larger gastric ulcers show delayed healing with conventional doses of H2-receptor antagonists during NSAID therapy. No such delay occurs with omeprazole therapy. The suggests that if NSAID-associated gastric ulcers are treated with H2-receptor antagonists, larger doses should be given for longer periods. In patients with no pre-existing ulcer disease, H2-receptor antagonists given prophylactically prevent duodenal but not gastric ulcers; sucralfate does the same. In individuals without peptic ulcer disease taking NSAIDs, misoprostol, given as prophylaxis, reduces the development of gastric ulcers; its beneficial effects on ulcer healing or symptoms during continued NSAID therapy, or its ability to prevent duodenal ulcers or ulcer complications, are not established. Because of diarrhea, the 400 micrograms/day dosage is recommended, especially in the elderly.
Have changing treatment patterns affected outcome for operable breast cancer? Ten-year follow-up in 1288 patients, 1965 to 1978. From 1965 to 1978, 1288 patients with primary operable breast cancer were treated by the senior author, using extended radical (ERM), radical (RM), and modified radical (MRM) mastectomy operations exclusively. Results were analyzed for trends in overall and disease-free survival, and patterns of local and distant relapse, the years 1965 to 1970 versus 1971 to 1974 versus 1975 to 1978. Significant changes (p less than 0.00001) from 1965 to 1978 included progressively earlier stage of disease, less frequent use of RM and ERM, a decline in the use of postoperative radiotherapy, and the introduction in 1975 of multidrug adjuvant chemotherapy. Ten-year disease-free survival rates improved significantly for all patients (by 11%, p = 0.00004) and for node-negative (by 12%, p = 0.0024), node-positive (by 8%, p = 0.012), clinical stage II (by 15%, p = 0.0022), and pathologic stage II (by 12%, p = 0.016) disease. Ten-year local recurrence for all patients was 3% (local only) and 2% (local with distant metastasis), and survival from date of recurrence for all patients failing treatment increased two times (p less than 0.0001) for patients treated most recently. As the primary surgical treatment of breast cancer continues to become more moderate, the promise of systemic adjuvant therapies can be realized only with continued emphasis on earlier diagnosis and maximal local control of disease.
Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Our experience treating perineal wounds secondary to abdominoperineal resection, either for inflammatory bowel disease or cancer, is presented. A total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection. All wounds were closed using the inferior gluteal myocutaneous flap. Fifteen of 16 patients have achieved healing, eight of whom had no complications. Only minor revisions or local wound care were required in the remaining patients, with only one patient failing to heal. Our results compare favorably with previous reports of treatment of this difficult problem.
Mid-line presentation of cervical lymphomata. Three cases of lymphoma are reported, all of which presented as a mid-line cervical swelling and appeared to be localised disease. The importance of early removal of such lesions is emphasized.
Natural history of moderate aortic stenosis. The natural history of severe, symptomatic aortic stenosis has been well documented. However, the natural history of moderate aortic stenosis remains poorly understood. Therefore, a group of 66 patients was identified who had a diagnosis of moderate aortic stenosis at the time of cardiac catheterization (aortic valve area 0.7 to 1.2 cm2) and who did not have surgical therapy during the 1st 180 days after cardiac catheterization. During a mean follow-up period of 35 months, 14 patients died of causes attributed to aortic stenosis and 21 underwent aortic valve replacement. The estimated probability for remaining free of any complication of aortic stenosis at the end of the first 4 years was 59%. Symptomatic patients with decreased ejection fraction or hemodynamic evidence of left ventricular decompensation were at greater risk for these complications. It is concluded that patients with moderate aortic stenosis are at significant risk for the development of complications.
Rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community. OBJECTIVE: To determine whether a small, isolated hospital that has no facilities to perform cesarean section and handles fewer than 50 deliveries annually can provide acceptably safe obstetric and perinatal care. DESIGN: Cohort study. SETTING: Southern region of the Queen Charlotte Islands, BC, served by a 21-bed hospital and medical clinic in Queen Charlotte City. The hospital and clinic are staffed by five family practitioners without local obstetric, pediatric, anesthetic or surgical support. PATIENTS: All women beyond 20 weeks' gestation who gave birth from Jan. 1, 1984, to Dec. 31, 1988; 33% were primiparous and 20% native. Of the 286 women 192 (67%) delivered locally, 33 (12%) were transferred after admission because of antepartum or intrapartum complications, and 61 (21%) delivered elsewhere by choice or on their physician's recommendation. OUTCOME MEASURES: Perinatal mortality rate and adverse perinatal outcome (death, birth weight of less than 2500 g, neonatal transfer or Apgar score of less than 7 at 5 minutes). MAIN RESULTS: There were six perinatal deaths, for a perinatal mortality rate of 20.8 (95% confidence interval [CI] 4.4 to 37.2). The hospital-based rate of adverse perinatal outcome was 6.2% (12 of 193 newborns) (95% CI 2.8% to 9.6%). CONCLUSIONS: The perinatal mortality rate is not a meaningful way to assess small populations; about 85 years of data would be required to decrease the 95% CIs from within 16 to within 4. The rate of adverse perinatal outcome in our study was consistent with the rate in other studies. Collaboration of small, rural hospitals is required to increase cohort size so that the correlation between the currently accepted standard, the perinatal mortality rate, and other outcome measures can be determined.
Pain relief achieved by transcutaneous electrical nerve stimulation and/or vibratory stimulation in a case of painful legs and moving toes. A patient is described with painful legs and moving toes. The pain had been occurring for more than 15 years, and a variety of therapies had been attempted with only partial, if any, success. Only morphine had succeeded in relieving the pain, but it had to be discontinued to avoid tolerance and dependence. We devised a treatment consisting of transcutaneous electrical nerve stimulation (TENS), vibratory stimulation (VS), and a combination of the two methods (TENS + VS). TENS brought about partial pain relief, but was less effective than VS; dual stimulation (TENS + VS) led to complete alleviation of the pain. Four months later, the patient was applying dual stimulation himself at home and was thus able to maintain complete relief with 3 or 4 weekly sessions. We suggest that dual stimulation results in a large-scale recruitment of large-diameter afferent fibres and may thus set up a powerful inhibitory control of nociception in our patient.
Effect of motion artefact on pulse oximeters: evaluation of four instruments and finger probes. The ability of the Ohmeda 3700, Nellcor N200, Datex Satlite Plus and Simed S100 pulse oximeters to detect induced hypoxaemia in the presence of motion artefact was assessed, under conditions of controlled vibration using an industrial vibration facility. Vibration at 4 Hz and 8 Hz induced increases in detection time for hypoxaemia and spurious decreases in the displayed SaO2 in some of the oximeters tested. Finger-dependent differences in oximeter performance and pulse rate registration were noted especially in those oximeters without ECG linkage (Ohmeda 3700 and Simed S100). Subsequently, eight different pulse oximeter finger probes were assessed for those characteristics that may predispose to motion artefact. There were marked differences in the mass of the probes, the forces exerted on the test finger and in the force required to displace the probes from the subject's finger. Differences in both the microprocessor programmes and the physical characteristics of the finger probes may explain the observed differences in function. Similar studies should form part of the standard evaluation of new pulse oximeters.
Clinical validation of a miniature nuclear probe system for continuous on-line monitoring of cardiac function and ST-segment A new, miniature cesium iodide/photodiode nuclear probe (the "Cardioscint") has been developed for continuous on-line measurement of left ventricular function and the ST-segment. Ejection fraction (EF) measurements in 77 patients were compared with gated equilibrium radionuclide ventriculograms. The probe was positioned over the left ventricle by first using a blind positioning algorithm and then by using the gamma camera. Background was measured both manually and automatically. There was good correlation between probe (positioned blind) and gamma camera EF with both manual (r = 0.80, n = 65) and automatic (r = 0.78, n = 66) backgrounds. Use of the gamma camera did not significantly alter the results. Correlation between the probe stroke counts and thermodilution-derived stroke index during atrial pacing in six subjects was also satisfactory (r = 0.69, n = 102). Thus, the Cardioscint is able to provide a reliable estimate of EF and can track rapid changes in cardiac volumes.
Acalculus lymphoeosinophilic cholecystitis associated with interleukin-2 and lymphokine-activated killer cell therapy. A case of unusual cholecystitis that developed on completion of interleukin-2 and lymphokine-activated killer cell therapy is described. A 62-year-old man was treated with interleukin-2 and lymphokine-activated killer cells for disseminated renal cell carcinoma. During the course of the immunotherapy, his serum alkaline phosphatase level increased, as did the peripheral eosinophil count (0.31). Subsequently, clinical and radiologic evidence of acute cholecystitis was noted. The removed gallbladder showed acalculus cholecystitis with extensive diffuse infiltrates of numerous eosinophils and T lymphocytes, but sparse polymorphonuclear leukocytes. The authors name this unusual cholecystitis acalculus lymphoeosinophilic cholecystitis and believe it to be associated with interleukin-2 and lymphokine-activated killer cell therapy. The pathogenic relationship is discussed.
Regression of intracardiac thrombus after embolic stroke. Using two-dimensional echocardiography, we studied the pathophysiology of intracardiac thrombus regression accompanied by anticoagulant therapy in 82 consecutive patients with acute cardiogenic cerebral embolism. We noted intracardiac thrombus in 15 patients; nine of the 15 were started on anticoagulant therapy with warfarin potassium to maintain the prothrombin time between 2.5 and 3.5 (international normalized ratio). Serial two-dimensional echocardiograms were obtained for these nine patients before and after anticoagulation, with the plasma levels of fibrinopeptide A, fibrinopeptide B beta 15-42, and D-dimer measured at the same time. In eight of the nine patients the intracardiac thrombi gradually decreased in size while the plasma level of fibrinopeptide A fell to within the normal range and the plasma levels of fibrinopeptide B beta 15-42 and D-dimer remained above the normal ranges. In the other patient the thrombus disappeared, with embolization to the right arm immediately after starting anticoagulant therapy. Mobile or small thrombi regressed earlier than nonmobile or large ones. We conclude that regression of intracardiac thrombi after anticoagulation may be based on the relative predominance of plasma fibrinolytic activity over anticoagulation-inhibited thrombin activity.