123rc/medical_text huggingface dataset:
Transesophageal echocardiography in evaluation and management after a Fontan procedure. Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn shunt could be evaluated in eight of nine patients (precordial in three of nine). Thrombus formation was detected by transesophageal studies in three patients (precordial in one patient); repeat studies were used to evaluate thrombolytic therapy in two. Atrioventricular valvular regurgitation (11 of 18 patients) was better defined by transesophageal than by precordial studies (5 of 18). A coronary artery fistula was identified in two cases (precordial in none). Transesophageal pulsed Doppler interrogation of pulmonary artery and pulmonary vein flow patterns consistently allowed a detailed evaluation of the Fontan circulation. Transesophageal echocardiography is an important diagnostic and monitoring technique after the Fontan procedure. In this series, it was far superior to precordial ultrasound evaluation and of substantial additional value to cardiac catheterization.
Neoplastic changes in the stomach after gastrectomy. Partial gastric resection for benign ulcer disease has been associated with an increased incidence of mucosal dysplasia and invasive adenocarcinoma, particularly 15 to 20 years after resection. These remnant carcinomas are particularly virulent with little hope of resection or cure once symptoms occur. Using a planned protocol of routine endoscopic surveillance with biopsy, the goal was to identify early markers of neoplasia, that is, dysplasia, and a diagnosis of adenocarcinoma of the gastric remnant, while both resection and cure were possible. Between July 1980 and August 1988, yearly flexible gastroscopic examination and random biopsy have been performed on 163 patients at least ten years after gastrectomy for benign ulcer disease. All biopsy results were interpreted for findings of dysplasia and early gastric adenocarcinoma. Results of this ongoing screening program revealed dysplasia of the gastric remnant in nine patients with eventual findings of adenocarcinoma in four of this group. These patients underwent total gastrectomy with findings of limited disease. Five patients with mucosal dysplasia continue to be observed at six month intervals. Three additional gastric carcinomas were found on initial gastroscopic screening, while one patient had adenocarcinoma diagnosed during a third yearly gastroscopic examination. These eight asymptomatic patients with adenocarcinoma in the gastric remnant had a postgastrectomy interval which ranged from 15 to 29 years (mean of 26.5 years). The results of this study support the concept of neoplastic change in the gastric remnant as a function of time from initial gastric resection. Findings of dysplasia on random biopsy indicate a greater likelihood of development of carcinoma of the gastric remnant and identify a subset of patients requiring aggressive endoscopic surveillance.
Secondary deposition of beta amyloid within extracellular neurofibrillary tangles in Alzheimer-type dementia. The hippocampal areas of 34 autopsy specimen brains from aged demented and nondemented subjects were examined using double staining of Bodian and beta protein. In 18 cases (75.5 +/- 7.4 years old), none of the extracellular neurofibrillary tangles (E-NFTs) were immunoreactive with beta protein. In 16 cases (82.9 +/- 5.4 years old), the minority of E-NFTs were immunoreactive with beta-protein antiserum. These beta-immunoreactive E-NFTs frequently appeared in the areas having senile plaques, while they were not observed in the area lacking beta-immunoreactive senile plaques. The ultrastructure of beta-immunoreactive E-NFTs revealed that they consisted of extracellular amyloid fibrils, extracellularly located bundles of paired helical filaments, astroglial processes and degenerating neurites. These findings suggest that the beta immunoreactivity of E-NFTs comes from secondary deposition of amyloid fibrils.
A composite driving system for LVAS and IABP: practical and effective driving and weaning. We have devised a new method, termed alternate synchronous driving (ASD), to wean patients from a left ventricular assist system (LVAS) to a pressure assist intraaortic balloon pump (IABP). We have built a new drive unit, VCT200, to apply ASD easily and automatically. After IABP insertion in the final weaning stage, this method drives the LVAS and IABP alternately, with electrocardiogram (ECG) synchronization. The pumping ratio of IABP increases while that of LVAS decreases according to recovery of natural heart function. In in vitro studies, ASD was effective when bypass flow (BF) was less than 50% of total flow (TF) (TF:BF + cardiac output [CO]), and its advantages increased under lower BF conditions. Mean aortic pressure (mAP) and CO increased 10 mmHg and 15%, respectively, with this method (IABP:LVAS = 1:1) when BF was 30% of TF. During in vivo studies, mAP increased 75.7 +/- 6.7 mmHg to 80.1 +/- 3.6 mmHg (p less than 0.001), and the CO increased from 3.1 +/- 0.5 L/min to 3.3 +/- 0.5 L/min (p less than 0.001), while the endocardial viability ratio (DPTI/TTI) increased 20-30%. This method was used in a 62-year-old man in which LVAS was applied after ventricular aneurysmectomy, BF was reduced from 2.2 L/min to 1.1 L/min by using ASD without any change in systemic perfusion. This reduction of BF could not be achieved with LVAS alone. From these data, this system could wean patients from LVAS and then switch to IABP smoothly, easily, and automatically, without hemodynamic instability.
Treatment of metastatic melanoma with an autologous tumor-cell vaccine: clinical and immunologic results in 64 patients. We treated 64 patients with metastatic melanoma using a melanoma vaccine preceded by low-dose cyclophosphamide (CY), and monitored immunologic effects and antitumor activity. On day 0, the patients were given CY 300 mg/m2 intravenously. Three days later, they were injected intradermally with vaccine consisting of 10 to 25 x 10(6) autologous, enzymatically dissociated, cryopreserved, irradiated (25 Gy) tumor cells mixed with bacillus Calmette-Guerin (BCG). This treatment sequence was repeated every 28 days. Of 40 assessable patients with measurable metastases, five had responses, four complete and one partial, with a median duration of 10 months (7 to 84+ months). In six additional patients, we observed an antitumor response that seems to be peculiar to this vaccine therapy: the regression of metastatic lesions that appeared after the immunotherapy was begun. Delayed-type hypersensitivity (DTH) to autologous, mechanically dissociated melanoma cells that had not been exposed to extraneous antigens, such as enzymes or fetal calf serum, increased significantly following immunotherapy (day 0 v day 49, P less than .001; day 0 v day 161, P less than .001; day 0 v day 217, P = .021). Antitumor responses to the vaccine were strongly associated with DTH, as indicated by three observations: (1) eight of 10 patients who exhibited tumor regression had positive DTH, (2) in postsurgical adjuvant patients, there was a highly significant linear relationship (P less than .001) between the intensity of DTH to autologous melanoma cells and the time to recurrence of tumor, and (3) nine patients who developed DTH to the autologous melanoma cells in their original vaccine developed new metastases that failed to elicit DTH or elicited a much smaller response. In three cases, we were able to excise regressing tumors for histologic examination; such tumors were characterized by an intense infiltration of lymphocytes. This demonstration that an immune response to melanoma-associated antigens can be elicited in cancer-bearing patients provides some basis for optimism about the prospects for developing active immunotherapy that has practical therapeutic value.
Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles. This study evaluated the effects of manual stretch of extrinsic finger flexor muscles on finger extension movement control and force control in 16 spastic hemiparetic subjects. These subjects were randomly divided into a control group and an experimental group. A group of able-bodied subjects also participated. A joint-movement tracking test (JMTT) quantified control of active finger extension movement at the metacarpophalangeal joint of the index finger within the available range of active movement, and a force tracking test (FTT) quantified control of isometric finger extension force at the same joint within the subject's available force range. Electromyographic activity was monitored in the extensor digitorum and flexor digitorum superficialis muscles during both tracking tests. Manual stretch was applied to the extrinsic finger flexor muscles of the experimental group between the pretest and posttest tracking tests. The JMTT performances of both control (p less than .025) and experimental (p less than .05) groups were significantly subnormal on the pretest as were FTT performances of controls (p less than .01) and study subjects (p less than .03). The JMTT improvement on posttest was significantly greater (p less than .05) in subjects than in controls. However, the change in FTT performance was not significantly different between the two groups. Manual stretch treatment, properly applied to extrinsic finger flexor muscles, is an effective method of temporarily improving the control of finger extension movement in spastic hemiparetic subjects.
A randomized, double-blind, placebo-controlled trial of oral antibiotic therapy following intravenous antibiotic therapy for postpartum endometritis. One hundred thirty-six patients were enrolled in a randomized, double-blind, placebo-controlled trial of oral antibiotic therapy (amoxicillin) versus placebo following successful intravenous (IV) antibiotic therapy for postpartum endometritis. No subjects were readmitted to the hospital for recurrent endometritis and there were no wound infections or recurrent fevers. Minor side effects were seen in 10% of those taking amoxicillin and 14% of those taking placebo. Compliance was fair; only 52% of those taking amoxicillin and 65% of those taking placebo completed therapy. The lack of infectious complications in this high-risk population suggests that oral antibiotic therapy is unnecessary after successful IV antibiotic therapy for endometritis.
Long term survival and severe rebleeding after variceal sclerotherapy. Of 197 consecutive patients with cirrhosis admitted because of bleeding from esophageal varices, 133 were included in a prospective study of elective sclerotherapy. We evaluated the incidence of extensive rebleeding and mortality rate. The period of study was 54 months and the mean follow-up period was 21 months. Forty-one patients had severe rebleeding and a majority of the episodes occurred during the first year. Only four patients had more than five sessions of sclerosis when rebleeding occurred. The probability rate for patients to be free of severe rebleeding after 48 months, according to Pugh's classification, was 88 per cent for those with grade A, 50 percent for grade B and 43 percent for grade C. The over-all mortality rate was 38.8 per cent (53 patients), with the highest rate noted during the first year. The mortality rate of patients with severe rebleeding was much higher than that of those who did not rebleed. Kaplan-Meier survival analysis at four years was 52 per cent, and survival rates in relation to Pugh's classification were 73 per cent for A, 53 per cent for B and 34 per cent for C. Differences between the three groups were statistically significant. Therefore, because of the high mortality rate associated with patients with cirrhosis and extensive rebleeding during the first year, it is important to achieve, as soon as possible, eradication of esophageal varices.
Prognostic indicators in invasive breast cancer. Tumor size and axillary lymph node involvement are the primary determinants of clinical course for most patients. Receptors for estrogen and progesterone are important additional prognostic factors for disease-free survival, overall survival, survival time after initial disease recurrence, and the likelihood of response to hormonal therapy. Histologic grading has merit as a prognostic factor, although poor reproducibility limits its broad application. Promising data have been emerging from the use of flow cytometry to analyze DNA content and proliferative rate. Patients with aneuploid tumors are more likely to have a shorter survival time than patients with diploid tumors. A high S-phase fraction also identifies a subset of patients at increased risk for early relapse. A combined index of ploidy and S-phase may be a more useful guide; together, diploidy and low S-phase identify a subgroup of node-negative patients at very low risk for disease recurrence. A number of oncogenes have been identified in breast cancer; amplification of the HER-2/neu gene or overexpression of the gene product may be an important prognostic indicator for node-positive patients.
Spermatic cord for onlay coverage of urethral defect. Segmental urethral necrosis may accompany scrotoperineal gangrene, and primary closure of the urethral defect may unacceptably reduce urethral dimensions. This dilemma has been managed successfully in 5 patients by application of the intact spermatic cord to the urethral defect and approximation to its margins. A representative case is described.
A note on the measurement of hypertension in HHANES Using data from the HHANES, we found the rates of elevated blood pressure readings on clinical examination to be extremely low for a sample of Mexican American and Puerto Rican women. The prevalence rates were one-fourth to one-fifth the rates found for a comparable sample of White women from NHANESII. These findings are discrepant with the little that is known about hypertension prevalence among Hispanics and with estimates of hypertension prevalence for Mexican Americans and Puerto Ricans drawn from NHANESII. While our HHANES samples women had much lower rates of clinical high blood pressure than Whites, they reported hypertension histories in excess of Whites. Rates of medicine usage among Hispanics were insufficiently large for effective treatment to explain the disparity. The prevalence estimates increased, but the relative discrepancies remained when we altered our sample specifications and clinical high blood pressure measure. A possible explanation for these discrepancies is that few physicians performed the majority of blood pressure readings in our HHANES sample. This may have been statistically inefficient. The discrepancies noted suggest that HHANES may not be a reliable source of information on hypertension among Hispanic women.
Endemic Cryptosporidium and Giardia lamblia infections in a Thai orphanage. We conducted a point prevalence survey for enteric protozoa in 205 institutionalized orphans 1-61 months of age in Bangkok, Thailand. Cryptosporidium was identified in 17 children (8%), Giardia lamblia in 42 (20%), and 3 children (1%) had both parasites. At the time of diagnosis, diarrheal symptoms were present in a minority of subjects: 36% of children with Cryptosporidium alone, 10% with G. lamblia alone, and in 20% of those with neither parasite. Although chronic nutritional status (height/age) was similar in all groups, acute nutritional status (weight/height) was lower only in children with Cryptosporidium (Z score = -1.39 +/- 0.13) compared with children with G. lamblia (mean Z score +/- SEM = -0.56 +/- 0.26) or neither parasite (Z score = -0.78 +/- 0.13; P = 0.05). Detectable levels of Cryptosporidium-specific IgG antibodies by ELISA were identified in 15 of 16 Thai children with Cryptosporidium and in 17 of 19 Thai children without Cryptosporidium (mean OD +/- SEM = 1.27 +/- 0.18 vs. 1.06 +/- 0.13, respectively), but in only 1 of 18 sera from toddlers in day-care centers in Denver, CO (OD = 0.128 +/- 0.03). Although neither infection with Cryptosporidium nor G. lamblia was consistently associated with acute diarrheal symptoms, Cryptosporidium was more often associated with depressed acute nutritional status than G. lamblia. The high prevalence of specific antibodies to Cryptosporidium in Thai orphans suggests an association between high rates of exposure with asymptomatic excretion of the parasites.
Pigmented spindle cell naevus. We report 22 cases of pigmented spindle cell naevus (PSCN). The usual appearance of these naevi is that of a heavily pigmented papule found mostly on the legs of young patients. Histologically, PSCN was characterized by symmetrical proliferation of spindle-shaped pigmented melanocytes grouped in large junctional nests. Pagetoid spread of single cells in the overlying epidermis was frequently found. In our opinion, PSCN is a distinctive benign acquired melanocytic naevus that in the past has been frequently misdiagnosed as atypical Spitz naevi or malignant melanoma.
Cytomegalovirus infections in bone marrow transplant recipients given intensive cytoreductive therapy. Cytomegalovirus (CMV) infections were studied in 785 bone marrow transplant recipients given intensive cytoreductive therapy. CMV excretion occurred in 24%, viremia in 9%, seroconversion in 40%, and overall active infection in 47%. CMV disease was much less common. Retinitis, enteritis, and pneumonitis occurred in only one, five (less than 1%), and 55 (7%) of the patients, respectively. Allograft recipients were more likely to develop CMV disease than were autograft patients (P = .0001) despite comparable rates of active CMV infection. CMV disease was rare after primary infection in both autograft and allograft recipients (0 and 1%, respectively). In contrast, CMV disease occurred in 16% of seropositive allograft recipients. Among allograft recipients, risk factors for CMV pneumonitis were seropositivity, age greater than 10 years, and acute graft-vs.-host disease, while the use of cyclosporine as prophylaxis against graft-vs.-host disease was protective. Although active infection rates did not decrease, the rates of CMV pneumonitis in allograft recipients during successive years declined significantly (P less than .001).
Multipiece tire rim injuries. Multipiece tire rims can explode during tire change, causing severe injury. Although more than 450 such accidents, with at least 80 deaths, have been recorded by the National Highway Traffic Safety Administration (NHTSA), we found no reports in the surgical literature on such injuries in the United States. This report describes experience with seven patients who sustained injuries in explosions of multipiece tire rims. All victims suffered massive maxillofacial trauma with associated ocular, cranial, intracranial, and extremity injuries. Two patients died, both because of intracerebral hemorrhage. One patient suffered serious long-term disability. All survivors required extensive reconstructive surgery. The design of the multipiece tire rim is inherently hazardous. Since many accidents of this type are not reported to the NHTSA, the incidence of such injuries may be significantly higher. An alternative, nonhazardous tire rim is available. Design modifications or a law restricting use of multipiece tire rims would prevent many accidents.
Coronary vascular remodeling and myocardial fibrosis in the rat with renovascular hypertension. Response to captopril. Progressive myocardial fibrosis, including the accumulation of collagen within the adventitia of intramyocardial coronary arteries, is seen in the hypertrophied rat myocardium secondary to renovascular hypertension (RHT) and has been held responsible for alterations in myocardial diastolic stiffness. This study was undertaken to test the hypothesis that this presumptive angiotensin-aldosterone mediated fibrosis and its functional consequences could be favorably altered by an antihypertensive oral dose (50 mg/kg/day) of the angiotensin converting enzyme (ACE) inhibitor captopril. Three groups were studied: control; untreated RHT for 8 weeks; treated RHT, with captopril started 48 h before banding and continued for 8 weeks. Interstitial collagen volume fraction and perivascular collagen area (morphometry), the fibrillar nature of collagen (picrosirius polarization), and the end diastolic stress-strain relation of the intact left ventricle were examined in each group. In comparison to untreated animals with RHT, we found that captopril, begun prior to banding, attenuated interstitial and perivascular fibrosis and prevented hypertrophy and the rise in diastolic stiffness 8 weeks later. Thus, an adverse accumulation of collagen in the interstitium and around intramyocardial coronary arteries, and its functional consequences in the rat with RHT, can be prevented by captopril. Other ACE inhibitors may have similar salutary effects, but remain to be evaluated. The pathogenetic origin of myocardial fibrosis in RHT requires further investigation, but appears to be related to the angiotensin-aldosterone system.
Gluten challenge in patients with celiac disease: evaluation of alpha 1-antitrypsin clearance. Our aim in this study was to monitor changes of the intestinal structure by alpha 1-antitrypsin clearance (alpha 1-ATCL) in order to offer an alternative to the gluten challenge biopsy. In addition, we evaluated the possibility of reducing the time of gluten challenge. Twelve patients had a presumptive diagnosis of celiac disease based on clinical and histological grounds. They were studied when the jejunal histology was normal after gluten-free diet and an alpha 1-ATCL was normal. The gluten was introduced by returning to a normal diet. The challenge lasted 4 wk. We measured alpha 1-ATCL at the end of the 1st and 4th wk, and a new jejunal biopsy was obtained at the end of the 4th wk. By wk 1, alpha 1-ATCL was abnormal in 11 patients but normal in one. By wk 4, alpha 1-ATCL was abnormal in 10 patients and still normal in one. The post-challenge biopsies showed atrophy in 11 and was normal only in the patient with normal alpha 1-ATCL at wk 1 and 4. One patient with abnormal alpha 1-ATCL had to stop the challenge at the first week. The patient with normal clearance at wk 1 and 4 and normal biopsy at wk 4 had abnormal results at 6 months. These data support our hypothesis that alpha 1-ATCL can be used as evidence of gluten toxicity after gluten challenge, and that this test can be abnormal as early as 1 wk after gluten is reintroduced.
Effects of prostaglandin E1 on collagen diseases with high levels of circulating immune complexes. Prostaglandin E1 (PGE1) was administered to 4 patients with collagen diseases presenting with high levels of circulating immune complexes (CIC) in sera. Our study patients had progressive systemic sclerosis, systemic lupus erythematosus, polyarteritis nodosa, and rheumatoid arthritis. In all 4 patients, CIC levels significantly decreased after administration of PGE1 by continuous infusion at 10/ng/kg/min via central venous catheter for 72 h. In addition, the skin ulcer in a patient with PSS healed completely, and the finger necrosis in a patient with RA improved. These results suggest that PGE1 given by continuous venous infusion is effective in reducing CIC, in addition to improving peripheral vascular disorders.