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Aged; Bladder Neoplasms/DI/PA/*TH; BCG Vaccine/*TU; Carcinoma/DI/PA/*TH; Case Report; False Negative Reactions; Female; Flow Cytometry/*; Human; Male; Middle Age; Support, U.S. Gov't, P.H.S..

Monitoring intravesical bacillus Calmette-Guerin treatment of superficial bladder carcinoma by serial flow cytometry.

JOURNAL ARTICLE.

Simultaneous urinary flow cytometry, cytologic, and cystoscopic examinations were performed at 3-month intervals for a minimum of 1 year on 29 patients receiving intravesical bacillus Calmette-Guerin (BCG) treatment of superficial bladder carcinoma. Flow cytometry (FCM) and cytology were concordant in 57 of 103 examinations; both FCM and cytology were positive in 38 instances, and carcinoma was confirmed by biopsy in 35 (92.1%). In 16 instances FCM and cytology were negative, but carcinoma was present on biopsy in 5 (31.3%). Three examinations were suspicious by both techniques. The 46 determinations with discordant FCM and cytology were subdivided into pathologically confirmed recurrences (25 instances) and no evidence of pathologic and/or cystoscopic disease (21 instances). In the 25 instances of recurrences, FCM was positive in 18 (72.0%), suspicious in 3 (12.0%), and negative in 4 (16.0%), while cytology was positive in 3 (12.0%), suspicious in 9 (36.0%), and negative in 13 (52.0%). Most patients had a severe BCG-induced inflammatory response that caused an elevation of the hyperdiploid population, believed secondary to epithelial regeneration and proliferation. In the 21 instances without detectable recurrence, hyperploidy led to a relatively high proportion of positive (15) and suspicious (4) results by FCM, but only eight had distinct aneuploid populations. It is possible that this latter group, at least, is harboring occult carcinoma. Conventional cytology in the nonrecurrent group was positive in 1 (4.8%), suspicious in 7 (33.3%), and negative in 13 (61.9%). In those instances when tumor was confirmed by biopsy, the false-negative rate for FCM was 19.7%; the false-negative rate for cytology was 40.9%. Thus, FCM appears to be more sensitive but less specific than conventional cytology, having a lower false-negative but a higher false-positive rate. Although serial FCM provides an objective quantitative measure of aneuploid stemlines and hyperdiploid populations in bladder irrigation specimens and can be helpful in following intravesical BCG therapy for superficial bladder carcinoma, it should still be used with conventional cytology. The greatest difficulty with FCM at present, as with conventional cytology, is in cases of marked inflammation. The results reported here were obtained under the most stringent conditions and represent the minimum level of accuracy. Potential improvements in the technique, with the addition of immunologic or other markers, hold hope of further increasing the accuracy of FCM.

Badalament RA; Gay H; Whitmore WF Jr; Herr HW; Fair WR; Oettgen HF; Melamed MR.

Cancer 8703; 58(12):2751-7

Aged; Biopsy; Bladder Neoplasms/PA/*RT/SU; Carcinoma, Transitional Cell/PA/*RT/SU; Human; Male; Middle Age; Preoperative Care; Support, U.S. Gov't, P.H.S..

Transitional cell carcinomas of the urinary bladder. Effects of preoperative irradiation on morphology.

JOURNAL ARTICLE.

The effects of preoperative irradiation on the morphology of transitional cell carcinomas (TCCs) were evaluated by studying the pretreatment biopsy and radical cystectomy specimens from 35 patients. Twenty-six of these patients had received 2000 rad within the week preceding surgery, and nine patients had received no preoperative treatment. The frequency of bladders without residual TCC was 23% for irradiated and 22% for nonirradiated cases. Of the TCCs classified as papillary in the biopsy specimens and irradiated, 79% lacked a papillary component at cystectomy, but in no case was the invasive component eliminated or regression from muscle invasion to superficial TCC noticed. Flat carcinoma in situ (CIS) did not respond to irradiation. At cystectomy nuclear pleomorphism was greater than at biopsy in 60% of the irradiated TCCs, whereas all nonirradiated cases retained the same grade as at biopsy. In addition, irradiation induced squamous differentiation in neoplastic cells only, without affecting the nonneoplastic urothelium.

Neumann MP; Limas C.

Cancer 8703; 58(12):2758-63

Heart Diseases/*PP; Heart Ventricle/*PP; Human.

The right heart.

JOURNAL ARTICLE.

The effects of preoperative irradiation on the morphology of transitional cell carcinomas (TCCs) were evaluated by studying the pretreatment biopsy and radical cystectomy specimens from 35 patients. Twenty-six of these patients had received 2000 rad within the week preceding surgery, and nine patients had received no preoperative treatment. The frequency of bladders without residual TCC was 23% for irradiated and 22% for nonirradiated cases. Of the TCCs classified as papillary in the biopsy specimens and irradiated, 79% lacked a papillary component at cystectomy, but in no case was the invasive component eliminated or regression from muscle invasion to superficial TCC noticed. Flat carcinoma in situ (CIS) did not respond to irradiation. At cystectomy nuclear pleomorphism was greater than at biopsy in 60% of the irradiated TCCs, whereas all nonirradiated cases retained the same grade as at biopsy. In addition, irradiation induced squamous differentiation in neoplastic cells only, without affecting the nonneoplastic urothelium.

Neumann MP; Limas C.

Cardiovasc Clin 8703; 17(2):1-273

Adult; Aged; Chronic Disease; Female; Heart Failure, Congestive/*PP; Heart Ventricle/PP; Hemodynamics; Human; Hypertension/PP; Male; Middle Age; Posture; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.; Vascular Resistance.

Assessment of right and left heart interactions: application of the resistance ratio in chronic congestive heart failure.

JOURNAL ARTICLE.

The effects of preoperative irradiation on the morphology of transitional cell carcinomas (TCCs) were evaluated by studying the pretreatment biopsy and radical cystectomy specimens from 35 patients. Twenty-six of these patients had received 2000 rad within the week preceding surgery, and nine patients had received no preoperative treatment. The frequency of bladders without residual TCC was 23% for irradiated and 22% for nonirradiated cases. Of the TCCs classified as papillary in the biopsy specimens and irradiated, 79% lacked a papillary component at cystectomy, but in no case was the invasive component eliminated or regression from muscle invasion to superficial TCC noticed. Flat carcinoma in situ (CIS) did not respond to irradiation. At cystectomy nuclear pleomorphism was greater than at biopsy in 60% of the irradiated TCCs, whereas all nonirradiated cases retained the same grade as at biopsy. In addition, irradiation induced squamous differentiation in neoplastic cells only, without affecting the nonneoplastic urothelium.

Cody RJ; Kubo SH.

Cardiovasc Clin 8703; 17(2):133-44

Coronary Disease/PP; Heart Failure, Congestive/PP; Heart Valve Diseases/PP; Heart Ventricle/PH/*PP; Human; Hypertension/PP.

Effect of the left ventricle on the right ventricle.

JOURNAL ARTICLE.

The importance of the once-obscure right ventricle is becoming evident. Even in disorders that primarily affect the left ventricle, the once-considered-passive conduit has proved essential for maintenance of normal cardiac output. In coronary artery disease, the function of the right ventricle is affected by both its circulation and the after-load placed on it by dysfunction of the left ventricle. In congestive heart failure, right ventricular function relates to functional capacity, whereas left ventricular function does not, and right ventricular ejection fraction is a useful prognostic guide in these patients. In mitral and aortic valvular disease, the role of the right ventricle is only now becoming evident, and the precise interplay of all factors has yet to be explained. In systemic hypertension, it is likely that the pulmonary circulation is affected by the same humoral factors that elevate systemic pressures.

Baker BJ; Franciosa JA.

Cardiovasc Clin 8703; 17(2):145-55

Animal; Chronic Disease; Coronary Disease/CO; Heart Enlargement/ET/*PA; Heart Failure, Congestive/ET/*PA; Heart Valve Diseases/CO; Heart Valves/PA; Heart Ventricle/*PA; Human; Hypertension/CO; Lung Diseases, Obstructive/CO.

The pathology of the right heart in chronic hypertrophy and failure.

JOURNAL ARTICLE.

The importance of the once-obscure right ventricle is becoming evident. Even in disorders that primarily affect the left ventricle, the once-considered-passive conduit has proved essential for maintenance of normal cardiac output. In coronary artery disease, the function of the right ventricle is affected by both its circulation and the after-load placed on it by dysfunction of the left ventricle. In congestive heart failure, right ventricular function relates to functional capacity, whereas left ventricular function does not, and right ventricular ejection fraction is a useful prognostic guide in these patients. In mitral and aortic valvular disease, the role of the right ventricle is only now becoming evident, and the precise interplay of all factors has yet to be explained. In systemic hypertension, it is likely that the pulmonary circulation is affected by the same humoral factors that elevate systemic pressures.

Murphy ML.

Cardiovasc Clin 8703; 17(2):159-69

Case Report; Coronary Disease/CO/SU; Female; Heart Failure, Congestive/*ET/PP/SU; Heart Ventricle/*PP; Human; Intraoperative Complications/*PP; Intraoperative Period; Male; Middle Age; Mitral Valve Stenosis/SU; Postoperative Complications/*; Preoperative Care; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S..

Perioperative right heart failure: etiology and pathophysiology.

JOURNAL ARTICLE.

A considerable amount of literature has been devoted to compromise of the right ventricle in spontaneous myocardial infarction. Little information is available regarding disproportionate dysfunction of the right ventricle associated with cardiac operation and the recovery period therefrom. Recognition of the problem is of paramount importance, if support measures are to be implemented. A great deal has yet to be learned regarding the appropriate support for the acutely failing right ventricle. Much remains to be accomplished regarding the assessment of right ventricle reserve, defining the role of risk factors, and quantitating the value of measures to optimally protect the right ventricle from injury during the perioperative period. Recognizing that the integrity of the right ventricle can be altered by numerous preoperative, perioperative and postoperative factors will provide an enlightened disposition on the part of the surgical team. Awareness of these considerations in the planning and conduct of surgical procedures should reduce morbidity and mortality from perioperative right ventricular failure. The imposition of new or unexpected morbidity during operation on a relatively unrelated problem represents surgical imperfection. Appropriate effort toward minimizing insult of the right ventricle could result in significantly decreasing the incidence and severity of perioperative right ventricular failure before the impetus of the continuing clinical problem dictates improvement in techniques to more appropriately treat this frequently preventable problem.

Fisk RL; Guilbeau EJ.

Cardiovasc Clin 8703; 17(2):219-29

Cardiopulmonary Bypass/*; Heart Failure, Congestive/*TH; Heart Ventricle; Heart-Assist Devices; Human; Intraoperative Complications/*TH; Lung/BS; Pulsatile Flow.

Perioperative right heart failure: treatment.

JOURNAL ARTICLE.

When right ventricular failure prohibits separation from cardiopulmonary bypass, standard methods of increasing pulmonary blood flow should be employed, including correction of hypoxia and acidosis, volume loading, and inotropic support of the right ventricle. Infusion of pulmonary vasodilators--particularly low-dose nitroprusside--should be used if the pulmonary vascular resistance is elevated. If pulmonary blood flow remains unsatisfactory, systemic intra-aortic balloon counterpulsation should be employed. In refractory cases, right-atrial-to-pulmonary-artery bypass using the Bio-Medicus centrifugal pump is the recommended therapy for those centers that do not have the Pierce-Donachy pneumatic ventricular assist-pump available. For refractory right ventricular failure following the surgical repair of congenital cardiac defects in which the placement of right atrial and pulmonary artery cannulae is not technically feasible, use of high-frequency high-volume ventilation appears to be quite promising. Utilization of pulmonary artery counterpulsation or the creation of an atrial septal defect may also be lifesaving, but is not recommended as the therapy of choice.

Gaines WE.

Cardiovasc Clin 8703; 17(2):231-8

Heart Failure, Congestive/DT/ET/*PP/SU/TH; Heart Ventricle/*PP; Human; Intraoperative Complications/DT/*PP/SU/TH; Support, Non-U.S. Gov't; Vascular Resistance.

Right ventricular failure associated with left ventricular failure.

JOURNAL ARTICLE.

RV and LV failure frequently coexist. Experimental evidence suggests that RV failure results from a primary insult to the right ventricle and an increase in pulmonary vascular resistance. LV failure results in an elevation of the left atrial pressure and thereby a reduction in the transpulmonary hydrostatic gradient. Because RV function depends on the contraction of the left ventricle, this contribution is reduced during LV failure. Treatment should be aimed first at restoring LV function. If RV failure persists and is not due to a simple mechanical problem, treatment of RV failure should be commenced. If volume loading, inotropes, and pH adjustments do not result in adequate RV output, a mechanical assist device should be considered. RHBP is the most powerful device, and it is capable of restoring systemic perfusion even when there is no residual RV function. Clinical results with this device have been most encouraging--most patients demonstrate improved RV function and a decrease in pulmonary vascular resistance after several days of treatment, allowing them to be weaned from assist. However, this technique is very invasive and requires constant close attention. PABC is a simple but less powerful assist device. Experimental studies suggest that if RV function is not extremely depressed--cardiac output is greater than 50 percent of normal--PABC may be effective in restoring systemic perfusion to normal levels. Current results suggest that RHBP remains the gold standard for severe RV failure, but further clinical experience with PABC may more clearly define its role in the management of RV failure.

Spence PA; Baylis CE; Peniston CM; Salerno TA.

Cardiovasc Clin 8703; 17(2):239-49

Heart Defects, Congenital/*PA; Heart Valve Diseases/CN; Heart Ventricle/AB; Human; Pulmonary Valve/AB; Tricuspid Valve/AB.

Pathology of congenital malformations of the right heart.

JOURNAL ARTICLE.

RV and LV failure frequently coexist. Experimental evidence suggests that RV failure results from a primary insult to the right ventricle and an increase in pulmonary vascular resistance. LV failure results in an elevation of the left atrial pressure and thereby a reduction in the transpulmonary hydrostatic gradient. Because RV function depends on the contraction of the left ventricle, this contribution is reduced during LV failure. Treatment should be aimed first at restoring LV function. If RV failure persists and is not due to a simple mechanical problem, treatment of RV failure should be commenced. If volume loading, inotropes, and pH adjustments do not result in adequate RV output, a mechanical assist device should be considered. RHBP is the most powerful device, and it is capable of restoring systemic perfusion even when there is no residual RV function. Clinical results with this device have been most encouraging--most patients demonstrate improved RV function and a decrease in pulmonary vascular resistance after several days of treatment, allowing them to be weaned from assist. However, this technique is very invasive and requires constant close attention. PABC is a simple but less powerful assist device. Experimental studies suggest that if RV function is not extremely depressed--cardiac output is greater than 50 percent of normal--PABC may be effective in restoring systemic perfusion to normal levels. Current results suggest that RHBP remains the gold standard for severe RV failure, but further clinical experience with PABC may more clearly define its role in the management of RV failure.

Edwards JE.

Cardiovasc Clin 8703; 17(2):35-44

Administration, Cutaneous; Administration, Oral; Drug Tolerance; Human; Infusions, Intravenous; Nitrates/*AD/ME; Ointments; Time Factors.

Tolerance to organic nitrates.

JOURNAL ARTICLE.

RV and LV failure frequently coexist. Experimental evidence suggests that RV failure results from a primary insult to the right ventricle and an increase in pulmonary vascular resistance. LV failure results in an elevation of the left atrial pressure and thereby a reduction in the transpulmonary hydrostatic gradient. Because RV function depends on the contraction of the left ventricle, this contribution is reduced during LV failure. Treatment should be aimed first at restoring LV function. If RV failure persists and is not due to a simple mechanical problem, treatment of RV failure should be commenced. If volume loading, inotropes, and pH adjustments do not result in adequate RV output, a mechanical assist device should be considered. RHBP is the most powerful device, and it is capable of restoring systemic perfusion even when there is no residual RV function. Clinical results with this device have been most encouraging--most patients demonstrate improved RV function and a decrease in pulmonary vascular resistance after several days of treatment, allowing them to be weaned from assist. However, this technique is very invasive and requires constant close attention. PABC is a simple but less powerful assist device. Experimental studies suggest that if RV function is not extremely depressed--cardiac output is greater than 50 percent of normal--PABC may be effective in restoring systemic perfusion to normal levels. Current results suggest that RHBP remains the gold standard for severe RV failure, but further clinical experience with PABC may more clearly define its role in the management of RV failure.

Abrams J.

Circulation 8703; 74(6):1181-5

Animal; Coronary Disease/DT/*PP; Dogs; Drug Evaluation; Drug Screening; Fibrinolytic Agents/TU; Heart/DE/*PP; Heart Ventricle/PP; Human; Myocardial Contraction/DE; Support, U.S. Gov't, P.H.S.; Systole/DE.

Assessment of ischemic regional myocardial dysfunction and its reversibility.

JOURNAL ARTICLE.

RV and LV failure frequently coexist. Experimental evidence suggests that RV failure results from a primary insult to the right ventricle and an increase in pulmonary vascular resistance. LV failure results in an elevation of the left atrial pressure and thereby a reduction in the transpulmonary hydrostatic gradient. Because RV function depends on the contraction of the left ventricle, this contribution is reduced during LV failure. Treatment should be aimed first at restoring LV function. If RV failure persists and is not due to a simple mechanical problem, treatment of RV failure should be commenced. If volume loading, inotropes, and pH adjustments do not result in adequate RV output, a mechanical assist device should be considered. RHBP is the most powerful device, and it is capable of restoring systemic perfusion even when there is no residual RV function. Clinical results with this device have been most encouraging--most patients demonstrate improved RV function and a decrease in pulmonary vascular resistance after several days of treatment, allowing them to be weaned from assist. However, this technique is very invasive and requires constant close attention. PABC is a simple but less powerful assist device. Experimental studies suggest that if RV function is not extremely depressed--cardiac output is greater than 50 percent of normal--PABC may be effective in restoring systemic perfusion to normal levels. Current results suggest that RHBP remains the gold standard for severe RV failure, but further clinical experience with PABC may more clearly define its role in the management of RV failure.

Ross J Jr.

Circulation 8703; 74(6):1186-90

Blood Flow Velocity; Comparative Study; Echocardiography/*/MT; Fetal Heart/*PH; Gestational Age; Heart Ventricle/PH; Human; Prospective Studies; Reference Values; Stroke Volume/*; Support, U.S. Gov't, P.H.S..

Changes in intracardiac blood flow velocities and right and left ventricular stroke volumes with gestational age in the normal human fetus: a prospective Doppler echocardiographic study.

JOURNAL ARTICLE.

We used Doppler echocardiography to quantitate the changes in intracardiac blood flow velocities and right and left ventricular stroke volumes in 80 normal human fetuses from 19 to 40 weeks gestation. Blood flow velocity spectra across the aortic, pulmonary, tricuspid, and mitral valves were digitized to obtain peak velocities (m/sec) and flow velocity integrals. Aortic and pulmonary diameters were measured at valve level from two-dimensional echocardiographic images and cross-sectional area was calculated assuming a circular orifice. Ventricular stroke volume was calculated as the product of the cross-sectional area of a great vessel and the flow velocity integral through that vessel. The pulmonary arterial and aortic diameters increased linearly with gestational age (r = .82, r = .84), and pulmonary arterial diameter consistently exceeded aortic diameter. There was a positive relationship between stroke volume and gestational age: stroke volume increased exponentially from 0.7 ml at 20 weeks to 7.6 ml at 40 weeks for the right ventricle (r = .87) and from 0.7 ml at 20 weeks to 5.2 ml at 40 weeks for the left ventricle (r = .91). Similar results were obtained for right and left ventricular and combined cardiac outputs. In 44% of the fetuses it was possible to quantitate both right and left ventricular stroke volumes. There was a close correlation between right and left ventricular stroke volumes in these fetuses (r = .96) and right ventricular stroke volume exceeded left ventricular stroke volume by 28%.(ABSTRACT TRUNCATED AT 250 WORDS)

Kenny JF; Plappert T; Doubilet P; Saltzman DH; Cartier M; Zollars L; Leatherman GF; St. John Sutton MG.

Circulation 8703; 74(6):1208-16

Adolescence/*; Androstenedione/BL; Apolipoproteins/BL; Caucasoid Race/*; Child; Dehydroepiandrosterone/AA/BL; Estradiol/BL; Human; Lipids/BL; Lipoproteins/*BL; Louisiana; Male; Negroid Race/*; Progesterone/BL; Sex Hormones/*BL; Sex Maturation; Support, U.S. Gov't, P.H.S.; Testosterone/BL.

Racial (black-white) comparisons of the relationship of levels of endogenous sex hormones to serum lipoproteins during male adolescence: the Bogalusa Heart Study.

JOURNAL ARTICLE.

The cross-sectional relationship of endogenous androgens (testosterone, androstenedione, and dehydroepiandrosterone sulfate [DHEA-S]), estrogen (estradiol) and progestin (progesterone) to serum levels of lipoprotein cholesterol (very low-density [VLDL], low-density [LDL], and high-density lipoprotein [HDL]) and apolipoproteins (apo A-I and apo B) were studied in white (n = 251) and black (n = 258) adolescent boys, ages 11 to 17 years, as part of the Bogalusa Heart Study. Black boys had significantly higher levels of estradiol, HDL cholesterol, and apo A-I, and lower levels of androstenedione and VLDL cholesterol than white boys, independent of age and adiposity. Age was correlated strongly with testosterone and androstenedione, and moderately with DHEA-S and estradiol levels in both races. However, only in white boys was age consistently related to VLDL cholesterol (positively), HDL cholesterol (negatively), and apo A-I (negatively). Overall, testosterone was associated inversely with HDL cholesterol and apo A-I in white boys, while progesterone was related positively to apo A-I in both races after adjusting for age and adiposity. However, these relationships were found to differ with age. Partial correlations between levels of sex hormones and lipoproteins adjusted for age and adiposity showed no associations in the 11 to 12 year age group in boys of either race. A significant positive relation of testosterone to VLDL cholesterol, and inverse relations of testosterone to HDL cholesterol and apo A-I and DHEA-S to HDL cholesterol were apparent only in white boys in the 13 to 14 year age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Srinivasan SR; Freedman DS; Sundaram GS; Webber LS; Berenson GS.

Circulation 8703; 74(6):1226-34

Cineradiography; Comparative Study; Coronary Disease/*RA/TH; Coronary Vessels/RA; Evaluation Studies; Follow-Up Studies; Heart Catheterization; Human; Image Processing, Computer-Assisted; Methods; Random Allocation; Retrospective Studies; Risk; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.; Time Factors.

Optimal detection of the progression of coronary artery disease: comparison of methods suitable for risk factor intervention trials.

JOURNAL ARTICLE.

To assess the best method of quantitating progression of coronary disease, we studied four measurements in 114 coronary segments from 35 medically treated patients from whom angiograms were obtained 5 years apart. Only stenoses of less than 70% that were visualized in nearly identical projections on both angiograms were evaluated. Vessel edges were measured by use of catheter calibration and an automated computer algorithm yielding two "absolute dimensions" (mean and minimum diameters) and two measurements (percent stenosis and atheroma area) that required a "normal reference" diameter. The coefficient of variation for repeated segment measurements was less for mean and minimum diameter than for percent stenosis and area of atheroma. The best measure of progression of coronary disease as determined by t test comparison of different methods was the change in mean diameter over time (6.7 +/- 14.1% decrease), whether calculated on a per coronary segment or per patient basis (p less than .001). Based on this measurement and its standard deviation of progression of coronary disease in this patient subset with relatively benign disease, it is estimated that 470 patients per group would be required for an interventional study to demonstrate a 33% reduction in disease progression (207 patients for 50% reduction) at a 95% confidence level and 90% power.

Ellis S; Sanders W; Goulet C; Miller R; Cain KC; Lesperance J; Bourassa MG; Alderman EL.

Circulation 8703; 74(6):1235-42

Angina Pectoris/*PP; Angina, Unstable/*PP; Cardiac Pacing, Artificial; Circadian Rhythm/*; Coronary Disease/*PP; Coronary Vessels/RA; Electrocardiography; Heart Atrium/PP; Heart Catheterization; Hemodynamics; Human; Male; Middle Age; Rest.

Resting angina with fixed coronary artery stenosis: nocturnal decline in ischemic threshold.

JOURNAL ARTICLE.

Atrial pacing was performed in 16 patients with angina at rest and significant coronary artery stenosis (greater than 70%) over 2 consecutive days in the morning (10 A.M. to 1 P.M.), in the afternoon (4 to 7 P.M.), and at night (12 midnight to 3 A.M.) to assess possible circadian variations of their ischemic threshold. Overall, the incidence of resting angina was highest at night. All pacing results were positive (greater than or equal to 1.0 mm ST segment shift) and tended to be reproducible in nine patients, whereas some or all were negative in seven. Among all positive results, ischemic thresholds at night were significantly lower than those in the morning and in the afternoon (125 +/- 3 vs 138 +/- 3 and 139 +/- 2 beats/min, mean +/- SEM; p less than .005). In nine patients, 19 pacing tests produced ST segment elevation, of which 13 were performed at night (68%). We conclude that patients with resting angina and severe coronary stenosis often exhibit a nocturnal decline in their ischemic threshold, which seems to facilitate development of transmural ischemia during atrial pacing.

Figueras J; Cinca J; Balda F; Moya A; Rius J.

Circulation 8703; 74(6):1248-54

Adult; Aged; Angina Pectoris, Variant/ET/*PP; Cold/DU; Coronary Vasospasm/ET/PP; Coronary Vessels/DE/*PP; Ergonovine/DU; Exertion; Female; Histamine/DU; Human; Hyperventilation/PP; Male; Middle Age; Support, Non-U.S. Gov't; Vasoconstriction/*/DE.

Local coronary supersensitivity to diverse vasoconstrictive stimuli in patients with variant angina.

JOURNAL ARTICLE.

It has been shown in different groups of patients with variant angina that coronary spasm can be reproduced by physiologic maneuvers and pharmacologic agents. It is not known, however, to what extent different stimuli can induce spasm in the same patient. To investigate whether coronary arterial spasm results from specific abnormal agonist-receptor interactions or from a local nonspecific coronary supersensitivity to different stimuli, 28 patients with vasospastic angina were submitted to a series of diverse vasoconstrictive stimuli known to provoke coronary spasm. Ergonovine, hyperventilation, handgrip, cold pressor, and exercise-tests, were carried out in all 28 patients. In the last 15 patients histamine was also administered. Spasm was provoked by ergonovine in 96% of patients, by hyperventilation in 54%, by histamine in 47%, by exercise in 46%, and by the cold pressor and handgrip tests in 11% and 7%, respectively. No significant differences were found in the responses to provocative tests of patients with normal coronary arteries or nonsignificant stenoses and those with significant lesions. In the same individual, spasm was induced by at least two vasoconstrictive stimuli, although with a different mechanism of action, in 82% of patients and spasm was induced by three or more stimuli in 39%. Tests were repeated in at least 23 patients and short-term reproducibility paralleled sensitivity. These results suggest that in patients with variant angina, a local nonspecific supersensitivity rather than an abnormal specific agonist-receptor interaction plays a major role in the genesis of coronary arterial spasm.

Kaski JC; Crea F; Meran D; Rodriguez L; Araujo L; Chierchia S; Davies G; Maseri A.

Circulation 8703; 74(6):1255-65

Comparative Study; Death, Sudden; Electrocardiography/MT; Follow-Up Studies; Heart Ventricle/PP/RI; Human; Membrane Potentials; Monitoring, Physiologic/MT; Myocardial Infarction/CO/DI/*PP; Prognosis; Prospective Studies; Risk; Stroke Volume; Support, Non-U.S. Gov't; Tachycardia/DI/PP; Time Factors; Ventricular Fibrillation/DI/PP.

Late potentials detected after myocardial infarction: natural history and prognostic significance.

JOURNAL ARTICLE.

The risk of developing spontaneous ventricular tachycardia (VT) and/or sudden death ("arrhythmic events") was prospectively assessed in 165 patients who survived acute myocardial infarction. Signal-averaged electrocardiograms (ECGs) were performed before hospital discharge and then serially at regular intervals over the following year. In addition, 24 hr Holter monitoring was performed and left ventricular ejection fraction was determined. Sixty-five patients (group 1) had abnormal signal-averaged ECGs (voltage in the last 40 msec of the filtered QRS less than 20 microV or filtered QRS duration greater than 120 msec), 92 had normal signal-averaged ECGs (group 2), and eight had bundle branch block (excluded from analysis). In group 1, spontaneous normalization of the voltage in the last 40 msec of the QRS complex occurred in 30% of patients after 12 months, although total filtered QRS duration did not change overall. During follow-up of up to 20 months (median 11), seven patients died suddenly and six presented again with spontaneous, symptomatic VT. Eleven of 65 (17%) group 1 patients had an arrhythmic event compared with one of 92 patients (1%) in group 2 (p less than .001). The sensitivity of the signal-averaged ECG as a predictor of arrhythmic events was 92% with a specificity of 62%. Patients with subsequent arrhythmic events had considerably lower voltage in the last 40 msec of the QRS (11.0 +/- 8.3 vs 32.0 +/- 21.9 microV; p less than .001) than those without such events, and longer filtered QRS complexes (121 +/- 14 vs 105 +/- 12 msec; p less than .001). Multivariate logistic regression determined that the signal-averaged ECG provided independent prognostic information from the presence of complex ventricular ectopy and the degree of left ventricular dysfunction assessed at the time of hospital discharge. Signal-averaged ECGs provide important prognostic information in identifying patients at risk of arrhythmic events after myocardial infarction. Dynamic changes in the terminal QRS voltage are observed during the first year after myocardial infarction.

Kuchar DL; Thorburn CW; Sammel NL.

Circulation 8703; 74(6):1280-9

Adult; Biopsy; Calcium Gluconate/PD; Comparative Study; Dobutamine/*PD; Endocardium/AN/DE/PA; Heart/*DE/PP; Heart Catheterization; Heart Failure, Congestive/*ME/PP; Hemodynamics/DE; Human; Male; Middle Age; Myocardium/*AN/PA; Radioligand Assay; Receptors, Adrenergic, Beta/*AN/DE; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S..

Assessment of the beta-adrenergic receptor pathway in the intact failing human heart: progressive receptor down-regulation and subsensitivity to agonist response.

JOURNAL ARTICLE.

We developed methods for identifying beta-adrenergic receptors in human right ventricular endomyocardial biopsy tissue with the radioligand (-)[125I]iodocyanopindolol (ICYP). Specific ICYP binding in a crude, high-yield membrane preparation derived from endomyocardial biopsy tissue was high (specificity greater than 90%), of high affinity (KD around 20 pM), saturable and stereospecific for the (-) vs the (+) isomer of isoproterenol. Subjects with mild-moderate and severe biventricular dysfunction had respective decreases in beta-adrenergic receptor density of 38.2% and 57.7% when normalization methods were averaged, with no significant differences in ICYP dissociation constant. A subgroup of subjects was subdivided by left ventricular ejection fraction (LVEF) into those with mild cardiac dysfunction (LVEF less than 0.50 greater than 0.40) and severe heart failure (LVEF less than 0.20) and given graded sequential infusions of dobutamine and calcium gluconate. Those with severe cardiac dysfunction had marked impairment of the dobutamine dP/dt and stroke work index response, whereas these responses to calcium did not differ in the two groups. These data indicate that in the intact human heart endomyocardial biopsy may be used for direct analysis of beta-adrenergic receptors, heart failure-associated myocardial beta-adrenergic down-regulation begins with mild-moderate ventricular dysfunction, reduction in myocardial beta-receptor density is related to degree of heart failure, and beta-receptor down-regulation is associated with pharmacologically specific impairment of the beta-agonist-mediated contractile response.

Fowler MB; Laser JA; Hopkins GL; Minobe W; Bristow MR.

Circulation 8703; 74(6):1290-302

Cardiac Output/*/DE; Cardiomyopathy, Congestive/DT/*PP; Coronary Disease/DT/PP; Diuretics/TU; Heart Catheterization; Heart Ventricle/DE/PP; Hemodynamics/DE; Human; Prospective Studies; Rheumatic Heart Disease/DT/PP; Vasodilator Agents/TU.

Maintenance of cardiac output with normal filling pressures in patients with dilated heart failure.

JOURNAL ARTICLE.

Therapy of elevated ventricular filling pressures in patients with dilated heart failure may be limited by concern that cardiac output will be further compromised. Twenty-five patients with severe symptoms and ejection fractions of 25% or less were studied to determine the lowest ventricular filling pressures that could be achieved with vasodilator and diuretic therapy while maintaining cardiac output. In 20 of 25 patients normal pulmonary capillary wedge pressures (PCWs) were achieved (mean 10 mm Hg compared with 30 mm Hg at baseline). Stroke volume was 60 vs 39 ml at baseline. Stroke work index was 30 vs 19 g-m/m2. For each patient, over the range of PCWs, stroke volume and stroke work index were maintained and were often maximal at the lowest PCW achieved. The upright position was well tolerated in patients with normal supine PCW. Normal filling pressures can be achieved in patients with congestive heart failure without compromise of cardiac output. While congestive symptoms should be improved, the feasibility and benefit of maintaining normal filling pressures over a long term must be established.

Stevenson LW; Tillisch JH.

Circulation 8703; 74(6):1303-8

Aortic Valve; Aortic Valve Insufficiency/PP/SU; Aortic Valve Stenosis/PP/SU; Heart Catheterization; Heart Valve Prosthesis/*; Hemodynamics/*; Human; Mitral Valve; Mitral Valve Insufficiency/PP/SU; Mitral Valve Stenosis/PP/SU; Postoperative Period; Prognosis; Stroke Volume; Systole.

Hemodynamic predictors of outcome in patients undergoing valve replacement [published erratum appears in Circulation 1987 Mar;75(3):650]

JOURNAL ARTICLE.

The afterload-corrected end-systolic volume index (ratio of end-systolic stress to end-systolic volume index [ESS/ESVI]) was previously useful in predicting outcome in patients with mitral regurgitation undergoing valve replacement. Therefore we tested ESS/ESVI together with standard hemodynamic variables as possible predictors of outcome in 39 patients with various valvular lesions who underwent valve replacement. Thirteen patients had preoperative mitral regurgitation, 16 had aortic stenosis, nine had aortic regurgitation, and one had mitral stenosis. Twenty-seven patients (group S) had a satisfactory outcome as defined by a return to NYHA class I or II together with a normal postoperative ejection fraction. Twelve patients who died, remained in class III or IV, or had a subnormal postoperative ejection fraction were deemed to have an unsatisfactory result (group U). Mean right atrial pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, end-diastolic volume index, end-systolic volume index (ESVI), and end-systolic wall stress were all greater in group U, whereas ESS/ESVI and ejection fraction were lower in group U. When these and other factors were submitted to stepwise discriminant multivariate analysis, ESS/ESVI and ESVI were the only independent predictors of outcome. However, when patients with mitral regurgitation (who might have biased the study) were excluded, discriminant analysis showed ESVI as the only independent predictive variable. We conclude that end-systolic indicators of ventricular function are superior to other standard hemodynamic variables in predicting outcome of valve replacement.

Carabello BA; Williams H; Gash AK; Kent R; Belber D; Maurer A; Siegel J; Blasius K; Spann JF.

Circulation 8703; 74(6):1309-16

Adolescence; Adult; Child; Child, Preschool; Color; Comparative Study; Echocardiography/IS/*MT; Evaluation Studies; Heart Septal Defects, Ventricular/*DI/PA; Heart Septum/PA/RA; Heart Ventricle/PA/RA; Human; Infant; Support, U.S. Gov't, P.H.S..

Color Doppler detection of multiple ventricular septal defects.

JOURNAL ARTICLE.

Combined two-dimensional and Doppler echocardiography has a high sensitivity and specificity for detection of isolated perimembranous ventricular septal defects. However, muscular or multiple ventricular septal defects may be difficult to diagnose with noninvasive methods, particularly in older children, necessitating angiography for accurate diagnosis. Detection of single and multiple ventricular septal defects with two-dimensional color flow mapping was compared with detection by standard two-dimensional imaging and Doppler. Both techniques were compared with four-chamber left ventricular angiography. Fifty-one patients (age 3 months to 25 years, mean 5.6 years) were studied. Eighteen had solitary ventricular septal defects, 18 had multiple ventricular septal defects, and 15 patients with intact ventricular septum served as a control group. At least one ventricular septal defect was detected by color Doppler and two-dimensional/Doppler methods in all patients with ventricular septal defect proved by angiography with no false positives. In the detection of multiple ventricular septal defects, the sensitivity of color Doppler was 72% and that of two-dimensional/Doppler was 38% (100% specificity in both). Color Doppler failed to identify multiple ventricular septal defects in five patients (two weighing less than 4 kg and three with reduced pulmonary blood flow). However, no large additional muscular defects were missed by imaging and color Doppler. Color Doppler is useful for the detection of ventricular septal defects and has higher sensitivity than two-dimensional/Doppler for multiple ventricular septal defects. The contribution of color Doppler appears to be in the detection of additional small muscular ventricular septal defects.

Ludomirsky A; Huhta JC; Vick GW 3d; Murphy DJ Jr; Danford DA; Morrow WR.

Circulation 8703; 74(6):1317-22

Adult; Aged; Comparative Study; Electrocardiography/IS/*MT; Electrodes; Female; Human; Male; Membrane Potentials; Microcomputers; Middle Age; Minicomputers; Support, Non-U.S. Gov't; Tachycardia/*DI/DT/SU; Time Factors; Vectorcardiography/IS/MT.

Characterization of the spatial distribution of late ventricular potentials by body surface mapping in patients with ventricular tachycardia.

JOURNAL ARTICLE.

Low-level activity at the end of the QRS complex was analyzed from 63 thoracic leads in 15 normal subjects and in 21 patients with ventricular tachycardia (VT). The latter had old myocardial infarction and no conduction disturbances and had not been receiving antiarrhythmic drugs. In both normal subjects and patients with VT, isopotential maps of the time-averaged and filtered (25 Hz high-pass) electrocardiograms during the terminal portion of the QRS were dipolar, i.e., they showed single positive and negative regions. For patients with VT, the extrema were either distant, with one over the precordial area and the other over the back, or close together in the precordial region. In 10 patients, maps recorded after administration of antiarrhythmic drugs remained the same while QRS duration was prolonged. In six patients, maps recorded before antiarrhythmic surgery showed distant extrema for septal or posterobasal VT sites of origin and close extrema for anterior or posteroapical sites. Generally, QRS duration was reduced and maps were modified after surgery. Late potentials can be well detected with only three orthogonal leads because their distributions are dipolar, but maps provide additional information about their distribution, which may be related to conduction delay sites and possibly to VT sites of origin. Sources near the torso surface would produce close extrema, whereas deeper sources would produce distant extrema.

Faugere G; Savard P; Nadeau RA; Derome D; Shenasa M; Page PL; Guardo R.

Circulation 8703; 74(6):1323-33

Adolescence; Adult; Arrhythmia/*DI; Child; Comparative Study; Computers; Electrocardiography/IS/*MT; Electrodes; Female; Heart Ventricle/PP; Human; Long QT Syndrome/*DI; Male; Middle Age; Vectorcardiography/MT.

Mapping of body surface potentials in patients with the idiopathic long QT syndrome.

JOURNAL ARTICLE.

Body surface potential maps were recorded from 140 chest leads in 25 patients affected by the idiopathic long QT syndrome (LQTS) and in 25 healthy control subjects matched for age and sex. Potential time integrals of the QRST and ST-T intervals were calculated at each lead point and displayed as isointegral (ISOI) maps. The main abnormalities noted on the QRST and ST-T ISOI maps were one area of negative values larger than normal in the right anterior and inferior thorax and a complex multipeak distribution of the integral values. At least one abnormality was present in 19 (76%) of the patients with LQTS and four (16%) of the control subjects (p less than .001). Each ISOI map was also represented as a weighted sum of nine fundamental components (eigenvectors) to detect and quantitate the nondipolar content. The percent contribution of the nondipolar eigenvectors (all eigenvectors beyond the third) was significantly higher in the LQTS group than in the control group (p less than .005). Specifically, an abnormally high nondipolar content on the QRST ISOI maps was observed much more frequently for patients with LQTS than for control subjects (nine or 36% vs one or 4%), and this was also true on the ST-T ISOI maps (14 or 56% vs one or 4%). No correlation was found between the major abnormalities on body surface maps and syncopal episodes. However, the high prevalence (76%) of these alterations among the patients with LQTS and their infrequent occurrence in the control population strongly suggests that they may be useful markers for the diagnosis of atypical cases. The prominent electronegative area on the anterior thorax can be related to delayed repolarization of a portion of the anterior wall of the heart. This finding is in agreement with the hypothesis that lower than normal right cardiac sympathetic activity is the main pathogenetic mechanism of LQTS. Multipeak distribution and high nondipolar content suggest regional electrical disparities in the ventricular recovery process. This may in part account for the high susceptibility of patients with LQTS to malignant arrhythmias.

De Ambroggi L; Bertoni T; Locati E; Stramba-Badiale M; Schwartz PJ.

Circulation 8703; 74(6):1334-45

Cardiac Pacing, Artificial; Cardiopulmonary Bypass; Cineradiography; Comparative Study; Computers; Electrocardiography/IS/*MT; Electrodes; Evaluation Studies; Heart Catheterization/IS/*MT; Heart Ventricle/PP/RA/SU; Human; Intraoperative Care/*MT; Support, Non-U.S. Gov't; Tachycardia/DI/SU.

Endocardial catheter mapping: wire skeleton technique for representation of computed arrhythmogenic sites compared with intraoperative mapping.

JOURNAL ARTICLE.

Guiding surgical therapy of ventricular tachycardia by preoperative endocardial catheter mapping necessitates improvement of the accuracy of localization of the arrhythmogenic site. We therefore used a new mathematical cineradiographic method during catheter mapping to compute the position of left ventricular arrhythmogenic sites relative to three anatomic reference points: the centers of aortic and mitral valve ostia and the left ventricular apex. To enable the surgeon to identify the position of the computed sites, a wire skeleton (one for each patient) representing a single or multiple arrhythmogenic site(s) relative to the anatomic reference points was constructed. This wire skeleton was inserted into the left ventricular cavity during surgery. Side branches of the device indicated preoperatively localized arrhythmogenic sites. Results in eight consecutive patients were compared with those of intraoperative simultaneous mapping of 64 endocardial sites. Sixteen morphologically distinct monomorphic ventricular tachycardias were mapped by catheter and 15 by intraoperative mapping. In 12 ventricular tachycardias an identical morphology was recorded during both techniques. The distance between arrhythmogenic sites localized with both methods was 1 cm or less in 11 of these 12 ventricular tachycardias and 2 cm in one ventricular tachycardia. These results indicate that endocardial catheter mapping combined with wire skeleton representation of computed positions of arrhythmogenic sites is reliable for guiding surgical therapy of ventricular tachycardia and since some of the ventricular tachycardias were inducible only during either preoperative or intraoperative mapping, both techniques have an additive value. In addition, the wire skeleton proved convenient during surgery by identifying the arrhythmogenic sites.

Hauer RN; de Zwart MT; de Bakker JM; Hitchcock JF; Penn OC; Nijsen-Karelse M; Robles de Medina EO.

Circulation 8703; 74(6):1346-54

Acetylprocainamide/BL; Aged; Cardiac Pacing, Artificial; Dose-Response Relationship, Drug; Drug Evaluation; Electrocardiography; Female; Heart Catheterization; Heart Conduction System/*DE; Heart Ventricle/DE; Human; Infusions, Intravenous; Male; Middle Age; Procainamide/*AD/BL; Prospective Studies; Tachycardia/BL/DT/*ET.

Effects of incremental doses of procainamide on ventricular refractoriness, intraventricular conduction, and induction of ventricular tachycardia.

JOURNAL ARTICLE.

The short-term effects of incremental doses of procainamide (7.5, 15, 22.5, and 30 mg/kg) on right ventricular effective refractory period, intraventricular conduction, and induction of ventricular tachycardia were determined in 31 patients who had a history of sustained, unimorphic ventricular tachycardia. QRS duration during incremental ventricular pacing was used as an index of rate-dependent changes in intraventricular conduction. The mean plasma procainamide concentrations corresponding to the incremental doses were 5.5 +/- 1.2 (+/- SD), 9.0 +/- 1.6, 12.6 +/- 2.2, and 16.3 +/- 3.2 mg/liter. Each incremental dose of procainamide up to a dose of 30 mg/kg resulted in a significant increment in right ventricular effective refractory period and each dose up to 22.5 mg/kg potentiated a rate-dependent prolongation of QRS duration. After the 7.5 mg/kg dose of procainamide, induction of ventricular tachycardia was suppressed in eight of 31 patients. After higher doses of procainamide, induction of ventricular tachycardia was suppressed in two additional patients. In three of 10 patients in whom the induction of ventricular tachycardia was suppressed by 7.5, 15, or 22.5 mg/kg of procainamide, sustained unimorphic ventricular tachycardia was again inducible after a higher dose of procainamide. In three of 31 patients, only nonsustained ventricular tachycardia was inducible after a 7.5 to 22.5 mg/kg dose of procainamide; however, in two of these three patients, sustained ventricular tachycardia was again inducible after administration of a higher dose of procainamide. In conclusion, during electropharmacologic testing with procainamide, it is worthwhile to test a dose of 7.5 mg/kg, because this dose is often effective in patients who respond to this drug. However, the results of this study indicate that procainamide may be effective in suppressing the induction of sustained ventricular tachycardia at a relatively low plasma concentration, but not at a higher plasma concentration. Therefore, during long-term therapy with procainamide it may be important to avoid plasma procainamide concentrations not only lower, but also higher than the concentration that results in the suppression of induction of tachycardia.

Morady F; DiCarlo LA Jr; de Buitleir M; Krol RB; Baerman JM; Kou WH.

Circulation 8703; 74(6):1355-64

Angina Pectoris/*TH; Angina, Unstable/DI/ET/*TH; Angioplasty, Transluminal/*/MT; Coronary Vessels/*/RA; Electrocardiography; Follow-Up Studies; Human; Myocardial Infarction/*CO/DI; Recurrence; Time Factors.

Coronary angioplasty for early postinfarction unstable angina.

JOURNAL ARTICLE.

Coronary angioplasty was performed in 53 patients in whom unstable angina had reoccurred after 48 hr and within 30 days after sustained myocardial infarction. Single-vessel disease was present in 64% of the patients and multivessel disease in 36%. The preceding myocardial infarction had been small to moderate in size in the majority of the patients. The left ventricular ejection fraction was more than 50% in 80% of the patients. Forty-five patients were refractory to pharmacologic treatment; eight were initially stabilized but once again became symptomatic with light exertion. Angioplasty was performed in 35 patients 2 to 14 days and in 18 patients 15 to 30 days after infarction (average 12 +/- 7 days after infarction). The initial success rate was 89% (47/53). The success rate of the patients treated at 2 to 14 days was lower (29/35, 83%) than that of patients treated at 14 to 30 days (18/18, 100%) but did not reach statistical significance (p less than .06). There were no deaths related to the procedure. In four of the six failures, emergency bypass surgery was performed and two patients sustained a myocardial infarction. Furthermore, a myocardial infarction complicated the angioplasty procedure in two other patients; thus the overall procedure-related myocardial infarction rate was 8% (4/53). At 6 months follow-up 26% (14/53) of all the patients who underwent angioplasty had recurrence of angina, which was successfully treated with repeat angioplasty, bypass surgery, or medical therapy. There were no late deaths. Late myocardial infarction occurred in two patients. Thus the total myocardial infarction rate after angioplasty at 6 months was 11% (6/53 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

de Feyter PJ; Serruys PW; Soward A; van den Brand M; Bos E; Hugenholtz PG.

Circulation 8703; 74(6):1365-70

Angioplasty, Transluminal/*AE/MT; Comparative Study; Coronary Disease/*CO/RA/SU; Coronary Vessels/*IN/RA/SU; Emergencies; Human; Prognosis; Time Factors.

Coronary dissection and total coronary occlusion associated with percutaneous transluminal coronary angioplasty: significance of initial angiographic morphology of coronary stenoses.

JOURNAL ARTICLE.

Coronary dissection and total coronary occlusion leading to emergency coronary surgery are the most frequent complications of percutaneous transluminal coronary angioplasty (PTCA) and their occurrence usually is unpredictable. To identify angiographic characteristics of coronary stenoses that may affect the incidence of these complications, the diagnostic pre-PTCA coronary angiograms of 38 consecutive patients (group I) undergoing emergency coronary surgery for dissection or occlusion were reviewed and compared with the angiograms of a random sample of 38 patients (stratified for left anterior descending and right coronary arteries) from a group of 1151 who did not need emergency coronary surgery (group II). Stenosis morphology before angioplasty was considered "complicated" if at least one of the following criteria was present: irregular borders, intraluminal lucency, and localization of stenosis in curve or at bifurcation. Baseline characteristics, maximum inflation pressures, types of balloon catheters used, and routinely registered angiographic stenosis properties (severity, length, eccentricity, and calcification) were similar in both groups. Irregular borders before PTCA were present in 22 of 38 patients in group I vs 10 of 38 in group II (p less than .05), intraluminal lucency in 22 of 38 vs nine of 38 (p less than .05), localization in curve in 27 of 38 pts vs 16 of 38 (p less than .05), and localization at bifurcation in 11 of 38 vs 15 of 38 (NS). Complicated angiographic morphology of coronary stenosis may represent a risk factor for dissection or occlusion. Therefore, although the predictive value of these findings is low, detailed evaluation of angiographic morphology of coronary stenoses may improve patient selection and reduce complication rates of PTCA.

Ischinger T; Gruentzig AR; Meier B; Galan K.

Circulation 8703; 74(6):1371-8

Comparative Study; Coronary Vessels/*/RA; Drug Evaluation; Electrocardiography; Heart Catheterization; Heart Ventricle/DE/RI; Hemodynamics/DE; Human; Hydroxybutyrate Dehydrogenase/BL; Myocardial Infarction/DT/EN/MO; Myocardium/EN; Streptokinase/*AD; Time Factors.

Which patients benefit most from early thrombolytic therapy with intracoronary streptokinase? [published erratum appears in Circulation 1987 Feb;75(2):394]

JOURNAL ARTICLE.

The effect of thrombolysis in acute myocardial infarction on enzymatic infarct size, left ventricular function, and early mortality was studied in subsets of patients in a randomized trial. Early thrombolytic therapy with intracoronary streptokinase (152 patients) or with intracoronary streptokinase preceded by intravenous streptokinase (117 patients) was compared with conventional treatment (264 patients). All 533 patients were admitted to the coronary care unit within 4 hr after onset of symptoms indicative of acute myocardial infarction. Four hundred eighty-eight patients were eligible for this detailed analysis, and 245 of these were allocated to thrombolytic therapy and 243 to conventional treatment. Early angiographic examinations were performed in 212 patients allocated to thrombolytic therapy. Patency of the infarct-related artery was achieved in 181 patients (85%). Enzymatic infarct size, as measured from cumulative alpha-hydroxybutyrate dehydrogenase release, was smaller in patients allocated to thrombolytic therapy (median 760 vs 1170 U/liter in control patients, p = .0001). Left ventricular ejection fraction measured by radionuclide angiography before discharge from the hospital was higher after thrombolytic therapy (median 50% vs 43% in control patients, p = .0001). Three month mortality was lower in patients allocated to thrombolytic therapy (6% vs 14% in the control group, p = .006). With the use of multivariate regression analysis, infarct size limitation, improvement in left ventricular ejection fraction, and three month mortality were predicted by sum of the ST segment elevation, time from onset of symptoms to admission, and Killip class at admission. Thrombolysis was most effective in patients admitted within 2 hr after onset of symptoms and in patients with a sum of ST segment elevation of 1.2 mV or more. On the other hand, no beneficial effects of streptokinase on enzymatic infarct size, left ventricular function, or mortality were observed in the subset of patients with a sum of ST segment elevation of less than 1.2 mV who were admitted between 2 and 4 hr after onset of symptoms.

Vermeer F; Simoons ML; Bar FW; Tijssen JG; van Domburg RT; Serruys PW; Verheugt FW; Res JC; de Zwaan C; van der Laarse A; et al.

Circulation 8703; 74(6):1379-89

Animal; Cerebrovascular Circulation; Comparative Study; Coronary Circulation; Dogs; Epinephrine/TU; Heart Arrest/MO/PP/*TH; Pressure; Respiration, Artificial/*; Resuscitation/*IS/MT; Support, U.S. Gov't, P.H.S.; Time Factors; Ventricular Fibrillation/PP/TH.

Vest inflation without simultaneous ventilation during cardiac arrest in dogs: improved survival from prolonged cardiopulmonary resuscitation.

JOURNAL ARTICLE.

Myocardial and cerebral blood flow can be generated during cardiac arrest by techniques that manipulate intrathoracic pressure. Augmentation of intrathoracic pressure by high-pressure ventilation simultaneous with compression of the chest in dogs has been shown to produce higher flows to the heart and brain, but has limited usefulness because of the requirement for endotracheal intubation and complex devices. A system was developed that can produce high intrathoracic pressure without simultaneous ventilation by use of a pneumatically cycled vest placed around the thorax (vest cardiopulmonary resuscitation [CPR]). The system was first tested in a short-term study of the maximum achievable flows during arrest. Peak vest pressures up to 380 mm Hg were used on eight 21 to 30 kg dogs after induction of ventricular fibrillation and administration of epinephrine. Microsphere-determined myocardial blood flow was 108 +/- 17 ml/min/100 g (100 +/- 16% of prearrest flow) and cerebral flow was 51 +/- 12 ml/min/100 g (165 +/- 39% of prearrest). Severe lung or liver trauma was noted in three of eight dogs. If peak vest pressure was limited to 280 mm Hg, however, severe trauma was no longer observed. A study of the hemodynamics during and survival from prolonged resuscitation was then performed on three groups of seven dogs. Vest CPR was compared with manual CPR with either conventional (300 newtons) or high (430 newtons) sternal force. After induction of ventricular fibrillation, each technique was performed for 26 min. Defibrillation was then performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Halperin HR; Guerci AD; Chandra N; Herskowitz A; Tsitlik JE; Niskanen RA; Wurmb E; Weisfeldt ML.

Circulation 8703; 74(6):1407-15

Analysis of Variance; Animal; Blood Flow Velocity/DE; Coronary Circulation/*DE; Dogs; Dose-Response Relationship, Drug; Flowmeters; Heart/*DE/PH; Hemodynamics/DE; Iohexol/DU/*PD; Support, Non-U.S. Gov't; Support, U.S. Gov't, Non-P.H.S.; Time Factors.

The immediate effects of iohexol on coronary blood flow and myocardial function in vivo.

JOURNAL ARTICLE.

Radiographic techniques used to quantify coronary blood flow all require bolus injection of contrast material, which markedly alters the flow being measured. Newer nonionic contrast agents have been shown to have fewer adverse hemodynamic, inotropic, and rheologic effects compared with ionic media and it has been suggested that they might not substantially affect coronary blood flow. Six dogs were instrumented with electromagnetic flow probes and subendocardial ultrasonic crystals. Intracoronary injections of iohexol (300 mg/ml iodine) were administered to establish a relationship between the dose and rate of contrast injection and the effect on flow and regional myocardial function. Two and 4 ml volumes of iohexol were injected at 3 ml/sec; 4 ml volumes were administered at 1 and 4 ml/sec. The 2 and 4 ml volumes decreased coronary flow by a mean of 31% (p less than .01) and 77% (p less than .001). The 4 ml injection at 1 and 4 ml/sec 77% (p less than .001) and 69% (p less than .001). The magnitude of the fall in flow was directly related to the dose, and the rate at which the flow nadir was attained was directly related to the rate of injection. Decrements in fractional shortening were temporally delayed by several beats compared with the flow changes and showed mean decrements of 19% to 29%. The effects on regional myocardial function were independent of contrast volume. However, the degree of dysfunction was more profound with slower infusion rates, suggesting that prolongation of contrast-induced ischemia was a major modulating factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Friedman HZ; DeBoe SF; McGillem MJ; Mancini GB.

Circulation 8703; 74(6):1416-23

Animal; Comparative Study; Coronary Circulation; Coronary Disease/DT/PP/RI; Dogs; Drug Screening; Female; Human; Male; Microspheres; Myocardial Infarction/*DT/PP/RI; Myocardium/PA; Necrosis; Recombinant Proteins/*TU; Superoxide Dismutase/*TU; Support, U.S. Gov't, P.H.S..

Reduction in experimental infarct size by recombinant human superoxide dismutase: insights into the pathophysiology of reperfusion injury.

JOURNAL ARTICLE.

To determine the importance of reperfusion injury and the ability of the free-radical scavenger recombinant human superoxide dismutase (h-SOD) to prevent it, open-chest dogs underwent 90 min of proximal circumflex coronary artery occlusion, and only at the moment of reperfusion received either h-SOD (400,000 IU bolus into the left atrium followed by a 300,000 IU iv infusion over 1 hr) or saline. After 48 hr the surviving animals were killed and measurements were made of the risk region (by postmortem angiography) and infarct size (by gross pathology). All measurements were made by investigators blinded to treatment given, and the code was broken only at the end of the study. Hemodynamic variables and collateral flow during ischemia were similar in the two groups. Infarct size in control animals (n = 8) averaged 22.4 +/- 3.1% of the left ventricle and 52.2 +/- 7.1% of the risk region, compared with 13.3 +/- 0.8% of the left ventricle and 33.6 +/- 2.1% of the risk region in h-SOD-treated dogs (n = 8) (p less than .05). Infarcts in treated animals were not only smaller, but also exhibited a distinctive "patchiness," suggesting protection along vascular distributions. Furthermore, analysis of the relationship between infarct size and collateral flow measured during ischemia in the two groups indicated that protection by h-SOD was greatest in animals with the lowest collateral flows. This study supports the concept that reperfusion of ischemic myocardium results in a separate component of cell damage, presumably linked to the generation of oxygen free radicals on reflow. Since the h-SOD preventable reperfusion component of injury was most pronounced in hearts with the most severe ischemia, scavenging of oxygen radicals at the time of reflow may offer a novel and particularly promising therapeutic approach for the protection of ischemic myocardium.

Ambrosio G; Becker LC; Hutchins GM; Weisman HF; Weisfeldt ML.

Circulation 8703; 74(6):1424-33

Animal; Comparative Study; Coronary Circulation; Dogs; Drug Screening; DTPA/*DU; Gadolinium/*DU; In Vitro; Myocardial Infarction/*DI; Myocardium/PA; Nuclear Magnetic Resonance/*DU/IS; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.; Tetrazolium Salts/DU.

Magnetic resonance imaging of acute myocardial infarction: gadolinium diethylenetriamine pentaacetic acid as a marker of reperfusion.

JOURNAL ARTICLE.

We examined the effects of a paramagnetic contrast agent, gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) on magnetic resonance images of acute myocardial infarction with and without reperfusion. Twenty-two dogs underwent occlusion of the left anterior descending coronary artery (LAD). In 10 dogs (group I) the LAD remained occluded for 3 hr and in the other 12 (group II) for 2 hr followed by 1 hr of reperfusion. Gd-DTPA (0.34 mM/kg) was administered to five dogs in group I at 2 hr and 5 min after occlusion and to seven dogs in group II 5 min after reperfusion. At 3 hr after ligation, the hearts were excised and imaged with spin echo and inversion recovery pulse sequences on a 0.35 Tesla magnetic resonance imager. Reperfused hearts given Gd-DTPA demonstrated a significant increase in contrast between normal and reperfused myocardium as compared with nonreperfused hearts and reperfused hearts not given Gd-DTPA. This enhancement was particularly prominent in the inversion recovery images. Studies performed in vivo in two additional dogs demonstrated similar enhancement with reperfusion with Gd-DTPA in gated spin echo images. Contrast-enhanced magnetic resonance imaging allows the detection of reperfusion early in the course of acute infarction.

Peshock RM; Malloy CR; Buja LM; Nunnally RL; Parkey RW; Willerson JT.

Circulation 8703; 74(6):1434-40

American Heart Association; Caloric Intake; Cardiovascular Diseases/*PC; Diet/*ST; Human; Nutritional Requirements; United States.

Dietary guidelines for healthy American adults. A statement for physicians and health professionals by the Nutrition Committee, American Heart Association.

JOURNAL ARTICLE.

This statement for physicians replaces the American Heart Association's Diet and Coronary Heart Disease, published in 1978. The current guidelines propose an optimal preventive diet for coronary heart disease. Emphasis is placed on the reduction of both saturated fat and total fat. Complex carbohydrates are recommended as the major replacement for calories from fat. Polyunsaturated and monounsaturated fats partially replace calories from other fat sources. Cholesterol and sodium guidelines are expressed relative to caloric intake, with an upper limit on each. The use of alcohol as a possible means of preventing cardiovascular disease is not advised. Maintenance of ideal body weight by calorie control and an adequate level of activity is emphasized.

Peshock RM; Malloy CR; Buja LM; Nunnally RL; Parkey RW; Willerson JT.

Circulation 8703; 74(6):1465A-1468A

Critical Care/*ST; Emergencies; Heart Diseases/*TH; Human; Resuscitation/*ST; Support, Non-U.S. Gov't.

Proceedings of the 1985 National Conference on Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care. July 11-13, Dallas, Texas.

JOURNAL ARTICLE.

This statement for physicians replaces the American Heart Association's Diet and Coronary Heart Disease, published in 1978. The current guidelines propose an optimal preventive diet for coronary heart disease. Emphasis is placed on the reduction of both saturated fat and total fat. Complex carbohydrates are recommended as the major replacement for calories from fat. Polyunsaturated and monounsaturated fats partially replace calories from other fat sources. Cholesterol and sodium guidelines are expressed relative to caloric intake, with an upper limit on each. The use of alcohol as a possible means of preventing cardiovascular disease is not advised. Maintenance of ideal body weight by calorie control and an adequate level of activity is emphasized.

Peshock RM; Malloy CR; Buja LM; Nunnally RL; Parkey RW; Willerson JT.

Circulation 8703; 74(6 Pt 2):IV1-153

Adolescence; Child; Child, Preschool; Emergency Medical Services/*; Health Services Needs and Demand/*; Health Services Research/*; Human; Infant; Life Support Care/*; Pediatrics/*; United States.

A needs assessment of advanced life support and emergency medical services in the pediatric patient: state of the art.

JOURNAL ARTICLE.

The outcome from cardiopulmonary arrest in children in the prehospital and hospital setting is generally poor. The event that compromises the cardiac status is often respiratory embarrassment, and the presenting rhythms are often bradyarrhythmias and asystole. Emergency medical services (EMS) systems have primarily an adult focus and may not be organized to manage optimally the critically ill and injured child. Data from a survey of training programs demonstrate that paramedic and EMT education in pediatric emergencies may be inadequate. Forty-one percent of the programs surveyed had less than 10 hr of pediatric training. Data suggest that EMS providers may not be equipped to manage children effectively. The Los Angeles EMS System for children is described. There are two levels of receiving facilities: Emergency Departments Approved for Pediatrics and Pediatric Critical Care Centers. The system is voluntary and has 85% of the hospitals in compliance with the guidelines. Early recognition of the prearrest state, improved training, and equipping of prehospital care personnel, development of EMS services for children, dissemination of an advanced pediatric life support course, as well as research in pediatric CPR may improve the outcome of resuscitation in the pediatric population.

Seidel JS.

Circulation 8703; 74(6 Pt 2):IV129-33

Allied Health Personnel/*; Community Health Services/*; Electric Countershock/*; Emergency Medical Technicians/*; Human; Support, U.S. Gov't, P.H.S.; United States.

Special considerations for defibrillation performed by emergency medical technicians in small communities.

JOURNAL ARTICLE.

Defibrillation by minimally trained ambulance technicians can significantly improve survival after out-of-hospital cardiac arrest in communities of all sizes. However, special consideration must be given to the development of such services in small communities, chiefly because of problems associated with the low volume of true emergency calls. Communities considering implementing programs by which defibrillation is performed by the emergency medical technician (EMT-D) must first evaluate their ambulance response times and, if inadequate, alter their system of ambulance response. After implementation of such a program, a permanent, formal skill maintenance program must be established. Defibrillation protocols must allow for the fact that many patients will refibrillate after successful conversion, yet no advanced care beyond the defibrillator will generally be available. Finally, every community instituting an EMT-D program must maintain a system of monitoring EMT performance and patient outcome that documents acceptable survival-to-discharge rates as well as the safety of the program. For smaller communities a regional or statewide evaluation system may be preferable to individual community programs.

Stults KR; Brown DD.

Circulation 8703; 74(6 Pt 2):IV13-7

Educational Measurement/MT; Human; Life Support Care/*ED; Resuscitation/*ED; Support, Non-U.S. Gov't.

Education and evaluation in emergency cardiac care programs (CPR and advanced cardiac life support): state of the art.

JOURNAL ARTICLE.

To increase the survival rate for out-of-hospital cardiac arrest, improvements in training must be made so that lay rescuers are motivated and have the ability to get involved. To overcome some of the fear and lack of involvement, better education strategies are needed. Adults learn didactic information through understanding and skills through repetition and reinforcement. Due to the fact that there is limited time that adults will commit to learning CPR, methods of simplification of the techniques need to be used so that there can be sufficient repetition and reinforcement. Teaching two-rescuer CPR to lay rescuers should not routinely be done. Most adults, particularly those around high-risk individuals, should learn one-rescuer CPR. Infant resuscitation should be taught predominantly to those around small children. Methods of reinforcement through the mass media should be attempted on a routine basis. Whenever possible the courses should be spread over a period of time to allow for repetition and reinforcement, thereby maximizing learning. Advanced cardiac life support (ACLS) should be widely taught to health professionals. ACLS instruction needs to be spread over time, whenever logistically possible, to enhance learning and retention. Good, validated examinations are needed and should be routinely rotated. Better methods of evaluation are needed to look at the benefit of these types of programs and to improve the cost-benefit ratio.

Atkins JM.

Circulation 8703; 74(6 Pt 2):IV18-22

Drowning/*TH; Human; Methods.

Near drowning.

JOURNAL ARTICLE.

Several conditions that contribute to drowning and near drowning must be considered in the treatment of near-drowned victims. Regardless of the cause, mechanical ventilation should begin as soon as possible and closed-chest cardiac massage should be administered when there is any question about the adequacy of cardiac output. After aspiration of either fresh or seawater, a large intrapulmonary physiologic shunt can occur, which requires aggressive mechanical ventilatory support to ensure adequate oxygenation and to return pulmonary function to normal. Near drowning is a multisystem disease and, while abnormalities of the lung and brain have been emphasized, definitive therapy must be tailored to each patient and must address all of the patient's needs.

Modell JH.

Circulation 8703; 74(6 Pt 2):IV27-8

Electric Countershock; Emergency Medical Services/*; Human; Life Support Care; Resuscitation; Support, Non-U.S. Gov't; United States.

Emergency medical service systems in acute cardiac care: state of the art.

JOURNAL ARTICLE.

Over the last two decades, emergency medical services in the United States have been greatly improved. Organization of prehospital providers of health care has improved the outcome of many patients, particularly the trauma patient and the acute cardiac patient. In Seattle as many as 40% of outside-the-hospital cardiac arrest victims with ventricular fibrillation have been saved when there is rapid delivery of basic life support by first responders followed by advanced life support by paramedics. Although these systems are growing and improving health care, many lack adequate medical control or physician involvement. Emergency medical service systems must have physicians involved in their management to meet their full capabilities. It has become apparent that four factors are critical in determining the ability to resuscitate an individual once a cardiac arrest has occurred: time to starting any of the rescue procedures, use of electrical defibrillation when indicated, use of epinephrine, and adequacy of the technique of basic life support, particularly the ventilation component. To provide defibrillation at the earliest possible time, defibrillation by first responders such as emergency medical technicians appears to be of benefit. With the advent of automatic and semiautomatic defibrillators, first responders and family members may also be able to defibrillate victims. The use of defibrillation by people with less training than paramedics, however, must be approached with caution to ensure that there is adequate medical control and that the individuals who use these devices are properly trained.

Atkins JM.

Circulation 8703; 74(6 Pt 2):IV4-8

Animal; Cough; Dogs; Human; Resuscitation/*MT; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S..

Modifications of cardiopulmonary resuscitation based on the cough.

JOURNAL ARTICLE.

The ability of cardiopulmonary resuscitation (CPR) to provide adequate vital organ blood flow during prolonged resuscitation has long been questioned, as has the mechanism of blood flow during CPR. Because coughing during cardiac arrest has been shown to produce adequate anterograde flow to maintain consciousness in man without compressing the heart, cough CPR has been used as a model of a pure "thoracic pump" mechanism on which to base modifications of CPR. In the thoracic pump mechanism, the left heart is a passive conduit for blood expressed from the pulmonary vasculature to the aorta, and there is selective flow to the brachiocephalic vascular bed because of its low pressure veins, which are protected by closure of thoracic inlet venous valves. Right heart flow from systemic veins to the lungs occurs between applications of pressure. Four alternative modalities exploiting the thoracic pump concept were studied in dogs during ventricular fibrillation with angiographic and pressure recordings: cough CPR, simultaneous chest compression and lung inflation, abdominal compression with lung inflation, and inflation of a vest and binder. The latter technique was associated with successful defibrillation and recovery after more than 30 min of circulatory support during ventricular fibrillation. Preliminary studies in a primate preparation indicate that this technique might be useful for prolonged circulatory support in man when defibrillation is not initially available or successful.

Criley JM; Niemann JT; Rosborough JP; Hausknecht M.

Circulation 8703; 74(6 Pt 2):IV42-50

Animal; Dogs; Heart Arrest/*TH; Heart Massage/*MT; Hemodynamics; Human; Support, U.S. Gov't, P.H.S..

The influence of manual chest compression rate on hemodynamic support during cardiac arrest: high-impulse cardiopulmonary resuscitation.

JOURNAL ARTICLE.

Considerable effort has been expended in recent years by a number of laboratories to improve methods of cardiopulmonary resuscitation. This article briefly summarizes 5 years of investigation by our group on hemodynamic support during external cardiac massage. In most studies, long-term canine preparations were used, and implanted transducers allowed precise hemodynamic measurements. Although cardiac output was depressed with all CPR methods, manual chest compressions of high velocity, moderate force, and brief duration at a rate of 120/min seemed to optimize systemic and coronary blood flow. This method was termed high-impulse CPR. High-impulse techniques now have been applied extensively in the clinical setting, and preliminary observations also support their efficacy in man. Based on this experience, it is suggested that the American Heart Association guidelines be changed to recommend a manual chest compression rate of 120/min during closed-chest cardiac massage.

Maier GW; Newton JR Jr; Wolfe JA; Tyson GS Jr; Olsen CO; Glower DD; Spratt JA; Davis JW; Feneley MP; Rankin JS.

Circulation 8703; 74(6 Pt 2):IV51-9

Airway Obstruction/*TH; Foreign Bodies/*TH; Human; Methods.

Foreign body airway obstruction: considerations in 1985.

JOURNAL ARTICLE.

Management of foreign body airway obstruction continues to be a major controversy in emergency medical care. Much of the disagreement is without doubt based on lack of a uniformly accepted model of acute airway obstruction representative of the clinical event. A variety of models have been used to assess different aspects of airway obstruction by foreign bodies. These models have analyzed, among other variables, kinetic energy and inertial and aerodynamic forces in attempts to focus on specific aspects of this controversy. Human volunteers, anesthetized and paralyzed patients, and cadavers have also been used. In several recent studies it was concluded that subdiaphragmatic pressure is the treatment of choice, while in at least one additional study firm back blows applied with the patient's head hanging downward were recommended as the treatment most likely to relieve airway obstruction. It seems likely that these apparently conflicting views can be reconciled and that a consensus recommendation for treatment of this emergency can be effected.

White RD.

Circulation 8703; 74(6 Pt 2):IV60-2

Heart Arrest/*TH; Human; Respiration, Artificial/*MT/ST; Respiratory Insufficiency/*TH.

Alternative methods of ventilation during respiratory and cardiac arrest.

JOURNAL ARTICLE.

Artificial ventilation is a cornerstone of basic life support-cardiopulmonary resuscitation (BLS-CPR). Recent data corroborate clinical studies performed in the 1950s and 1960s, suggesting a need to change the present American Heart Association standards for artificial ventilation. These studies show that gastric insufflation followed by regurgitation and pulmonary aspiration are a major hazard of artificial ventilation with an unprotected airway. Present BLS-CPR standards require that ventilation be performed rapidly between external chest compressions or with incremental breaths. These methods of ventilation predispose the victim to gastric insufflation. Alternative methods of ventilation with longer inspiratory time and thus lower flow rate and peak inspiratory pressure are suggested. Additionally, rescue personnel, particularly EMTs and paramedics, should be taught how to apply cricoid pressure to prevent gastric insufflation in victims with an unprotected airway.

Melker RJ.

Circulation 8703; 74(6 Pt 2):IV63-5

Animal; Bicarbonates/*TU; Dogs; Resuscitation/*MT; Sodium/*TU; Support, U.S. Gov't, P.H.S.; Ventricular Fibrillation/*TH.

Failure of sodium bicarbonate to improve resuscitation from ventricular fibrillation in dogs.

JOURNAL ARTICLE.

To determine the value of sodium bicarbonate in resuscitation from ventricular fibrillation and the prevention of spontaneous refibrillation, sodium bicarbonate (1 meq/kg) or placebo was administered on a random basis to 16 pentobarbital-anesthetized dogs 18 min after the induction of ventricular fibrillation and cardiopulmonary resuscitation. Defibrillation was attempted 2 min after the administration of bicarbonate or placebo. All animals were successfully defibrillated, but three of eight bicarbonate-treated and two of eight control animals died in electromechanical dissociation (p = NS). Spontaneous refibrillation occurred in three animals in each group (p = NS). Successful resuscitation was not dependent on treatment, arterial or mixed venous Pco2, or arterial or mixed venous pH but correlated strongly with coronary perfusion pressure (p less than .003). Spontaneous refibrillation occurred without relation to any identifiable variable. The gradient between diastolic aortic and right atrial pressures was 24 +/- 2 mm Hg in controls and 23 +/- 2 mm Hg in treated animals over the entire 20 min of cardiopulmonary resuscitation (p = NS). However, among animals successfully resuscitated, mean diastolic coronary perfusion pressure averaged 27 +/- 2 mm Hg compared with 20 +/- 1 mm Hg among those dying in electromechanical dissociation (p less than .02). For the final 2 min of resuscitation, after drug administration, these gradients were 31 +/- 2 and 23 +/- 2 mm Hg, respectively (p less than .01). Microsphere determined myocardial perfusion correlated with the diastolic aortic-right atrial perfusion pressure gradient (r = .86) and was 0.43 +/- 0.03 ml/min/g in survivors and 0.22 +/- 0.01 ml/min/g in nonsurvivors (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Guerci AD; Chandra N; Johnson E; Rayburn B; Wurmb E; Tsitlik J; Halperin HR; Siu C; Weisfeldt ML.

Circulation 8703; 74(6 Pt 2):IV75-9

Allied Health Personnel/*/ED; Electric Countershock/*/ED; Emergency Medical Technicians/*/ED; Human; Support, U.S. Gov't, P.H.S.; United States.

Defibrillation performed by the emergency medical technician.

JOURNAL ARTICLE.

As a means of providing defibrillation as soon as possible for those suffering out-of-hospital ventricular fibrillation, numerous communities have trained and authorized emergency medical technicians (EMTs) to provide defibrillatory shocks (EMT-D). The findings of four controlled studies and the experience of various communities have answered important questions. EMT-D programs have been shown effective in urban, suburban, and rural communities with and without paramedic backup. EMT-D programs appear safe, with errors of commission being extremely rare and errors of omission being of acceptably low incidence. Issues still to be resolved include the degree and amount of training that should be given and whether manual or automatic defibrillators should be used. Medical supervision and quality control is the most important aspect of EMT-D programs. At its core, the success of EMT-D programs is confirmation of the principle of early defibrillation. Wider dissemination of early defibrillation will improve survival from sudden cardiac death.

Eisenberg MS; Cummins RO.

Circulation 8703; 74(6 Pt 2):IV9-12

Conversion Disorder/*ET; Esophagogastric Junction/PP; Esophagus/PP; Gastroesophageal Reflux/CO; Gastrointestinal Diseases/CO/DI; Human; Manometry; Pressure.

The globus sensation.

JOURNAL ARTICLE.

As a means of providing defibrillation as soon as possible for those suffering out-of-hospital ventricular fibrillation, numerous communities have trained and authorized emergency medical technicians (EMTs) to provide defibrillatory shocks (EMT-D). The findings of four controlled studies and the experience of various communities have answered important questions. EMT-D programs have been shown effective in urban, suburban, and rural communities with and without paramedic backup. EMT-D programs appear safe, with errors of commission being extremely rare and errors of omission being of acceptably low incidence. Issues still to be resolved include the degree and amount of training that should be given and whether manual or automatic defibrillators should be used. Medical supervision and quality control is the most important aspect of EMT-D programs. At its core, the success of EMT-D programs is confirmation of the principle of early defibrillation. Wider dissemination of early defibrillation will improve survival from sudden cardiac death.

Linsell JC; Owen WJ.

Clin Otolaryngol 8703; 11(5):303-5

Carcinoma/PA/*RA/SU; Case Report; Human; Laryngeal Neoplasms/PA/*RA/SU; Laryngectomy; Male; Neoplasm Staging; Tomography, X-Ray Computed/*.

Computed tomography: a mandatory investigational procedure for the T-staging of advanced laryngeal cancer.

JOURNAL ARTICLE.

Eighteen patients underwent computed tomography (CT) prior to total laryngectomy. In order to assess the accuracy of CT scanning in the evaluation of carcinoma of the larynx, CT scans were prospectively interpreted and the extent of the tumour was recorded. The tumour extent was evaluated on whole-mount histologic sections of the laryngeal specimens, prepared in the horizontal plane, similar to the CT scan. The results were compared to assess the ability of CT to identify tumour infiltration in the horizontal plane accurately. Based on these findings it is clear that CT has its influence on the T-staging and on the choice of treatment of laryngeal cancer, i.e. radiotherapy versus surgery.

Gerritsen GJ; Valk J; van Velzen DJ; Snow GB.

Clin Otolaryngol 8703; 11(5):307-16

Adolescence; Child; Child, Preschool; Human; Infant; Parents/*; Pharyngitis/*ET; Regression Analysis; Smoking/*; Tobacco Smoke Pollution/*AE; Tonsillectomy.

Children's sore throats related to parental smoking.

JOURNAL ARTICLE.

There has been concern that the smoking of tobacco can adversely affect the health of non-smokers. This is most cogent in children who are subject to smoke at home. The aim of this study is to relate children's sore throats to the smoking habits of their parents. The parents of 154 children were asked about the age, sex, birthweight, method of postnatal feeding and age at starting school or day nursery of the child, the frequency of sore throats, smoking habits and history of tonsillectomy of all members of the household, the size of family, the dwelling size, and the occupation of the father. Analysis by multiple regression showed a significant association between children's sore throats and maternal smoking. Reduction in domestic cigarette smoke exposure should benefit the child by reducing the number of sore throats he or she suffers.

Willatt DJ.

Clin Otolaryngol 8703; 11(5):317-21

Adolescence; Bacterial Infections/*ET; Child; Child, Preschool; Human; Middle Ear Ventilation/*AE; Otitis Media with Effusion/*ET/MI; Prospective Studies; Risk; Swimming/*.

Bacteriological aspects of swimming with grommets.

JOURNAL ARTICLE.

A prospective bacteriological and symptomatic study was carried out on 50 swimmers and 50 non-swimmers who had grommets inserted for secretory otitis media. The risk of developing otorrhoea with positive bacterial pathogens was similar for swimmers (7.9%) and non-swimmers (8.0%). Subdividing the non-swimmers into 'wetters' and 'strictly dry' there was a similar risk of ear symptoms and pathogens. All children who swim before the insertion of grommets should continue to do so postoperatively with no added risk of ear infections.

el Silimy O; Bradley PJ.

Clin Otolaryngol 8703; 11(5):323-7

Adult; Female; Human; Male; Nose/*PH; Respiratory Airflow/*; Support, Non-U.S. Gov't; Thermography/IS/*MT.

A non-invasive method of demonstrating the nasal cycle using flexible liquid crystal thermography.

JOURNAL ARTICLE.

The relationship between air flow at 38 degrees C and area colour change on a flexible liquid crystal film was found to be virtually linear between the values of 1 and 31 min-1 cm-2. This value of flow per unit area corresponded to values expected at the level of the nostril during quiet breathing. A series of 6 subjects were asked to breathe over a flexible liquid crystal film regularly during the day and the area of colour change produced by flow from each nostril was examined. Four subjects showed a regular change in relative flow through each nostril whilst 2 subjects showed a constant flow through each nostril. This simple and non-invasive technique provides a method of examining the nasal cycle in adults and children in health and disease.

Canter RJ.

Clin Otolaryngol 8703; 11(5):329-36

Carcinoma/*PA/PP; Cell Movement; Human; Laryngeal Neoplasms/*PA/PP; Lymphocytes/PH; Microscopy/*MT; Mitosis; Photography; Videotape Recording/*.

Video time-lapse microscopy of human laryngeal carcinomas in vitro.

JOURNAL ARTICLE.

Twelve human laryngeal carcinomas and 14 normal vocal cord epithelia were studied in vitro by the method of tissue culture incorporating video time-lapse microscopy. Different events were photographed by taking 'stills' from the television monitor during play-back. Outgrowths from both tumour and normal explants formed only as monolayers. Mitoses were mainly found to be localized approximately mid-way between explant and the edge of the outgrowth. Some cells were seen to become suddenly active producing oscillating blebs and sometimes they detached themselves from the monolayer culture and changed appearance. This was more prevalent in the tumour cultures. In both tumour and normal cell cultures lymphocytes were observed and their normal chemokinetic movement was changed into a rapid chemotactic attraction by the presence of a mitotic epithelial cell. These lymphocytes appear to represent T-suppressor cells. The present study has shown that primary tissue culture can be a valuable tool in the study of laryngeal carcinoma. The interaction between mitotic tumour cells and lymphocytes may represent a transformation of T-lymphocytes into LAK cells.

Wang H; Boxall J; Hellquist H; Proops D; Michaels L.

Clin Otolaryngol 8703; 11(5):337-43

Carcinoma/*GE/PA; Cell Division; Epithelium/PA; Human; Hyperplasia; Laryngeal Neoplasms/*GE/PA; Polyploidy/*; Precancerous Conditions/*GE/PA; Support, Non-U.S. Gov't; Vocal Cords/*PA.

Hypertetraploid cells in vocal cord epithelia.

JOURNAL ARTICLE.

DNA measurements yield information about the nature of cells and may provide diagnostic and prognostic information. Static cytofluorometry was performed on smears removed at microlaryngoscopy from 107 vocal cord lesions (96 patients). All stem cell lines were diploid except 3; 2 carcinomas and 1 severe dysplasia were polyploid. The mean proliferative activity (percentage of nuclei greater than diploid peak) was 2.1% for the group of epithelia with hyperplasia and mild dysplasia, 3.1% for those with moderate dysplasia, 4.0% for severe dysplasia, and 6.8% for carcinomas. Hypertetraploid cell nuclei (HT cells) were not found in epithelia with hyperplasia and mild dysplasia. Seven out of 15 patients with epithelia showing moderate dysplasia had HT cells; 5 of these patients developed a carcinoma. One of 8 without HT cells developed a severe dysplasia. Nine patients with severe dysplasia had HT cells; 4 had recurrences and 4 developed carcinoma within 4 years. In 14 patients without HT cells, 3 had recurrences and 1 developed a carcinoma 6 years later. HT cells were found in 15 patients with T1 & T2 carcinomas; residual carcinoma was present in 2 after radiotherapy and 4 had recurrences within 11 months. Fourteen patients with T1 & T2 carcinoma did not have any HT cells; one had residual carcinoma after radiotherapy and 3 had recurrences between 18 months and 4 years. DNA measurements and, especially, the demonstration of epithelia with HT cells prove to be of prognostic importance.(ABSTRACT TRUNCATED AT 250 WORDS)

Olofsson J; Franzen G; Lundgren J.

Clin Otolaryngol 8703; 11(5):345-51

Ethmoid Bone/SU; Human; Orbit/*SU.

The Patterson operation for decompression of the orbit.

JOURNAL ARTICLE.

A modification of Patterson's external antro-ethmoidectomy operation is described which provides a more direct and simpler approach than the transantral operation for decompression of the orbit.

von Haacke NP; Wilson JA; Dale BA; Adams GG.

Clin Otolaryngol 8703; 11(5):365-7

Adult; Epistaxis/*ET; Female; Follow-Up Studies; Human; Male; Nasal Mucosa/*BS; Recurrence; Support, Non-U.S. Gov't; Varicose Veins/CO/*SU.

Transection of varicose vessels in the nasal mucosa of patients with recurrent epistaxis. A 2-year follow-up.

JOURNAL ARTICLE.

Twenty-two patients with recurrent nose bleeds and varicose vessels on the nasal septum were subjected to transection of the vessels and followed-up for 2 years. One month after the operation, it was not possible to identify the original vessels. In other locations new varicose vessels began to appear after 1 month, and at the end of the follow-up period were observed on 9 out of 10 operated sides. The transection resulted in an immediate decrease in the frequency of nose bleeds and at the end of the control period 12 (55%) of the patients had had less than 4 bleeds during the previous year in spite of the observed rapid formation of new vessels. Mucosal atrophy with symptoms of increased nasal crusting occurred in 3 patients. Transection of varicose vessels in patients with nose bleeds leads to a decrease in the number of bleeds.

Beran M; Petruson B.

Clin Otolaryngol 8703; 11(5):369-72

Animal; Cats; Denervation; Ganglia, Autonomic/*UL; Human; Nasal Mucosa/DE/*IR/SE; Neostigmine/PD; Rhinitis, Vasomotor/*ET/SU.

Autonomic microganglia of the nasal mucosa and their relation to vasomotor rhinitis.

JOURNAL ARTICLE.

The classical concept of the autonomic innervation of the nasal mucosa states that the postganglionic sympathetic neurones lie in the superior cervical ganglion and those of the postganglionic parasympathetic neurones are in the pterygopalatine ganglion. We have carried out a study of the fine structure of the respiratory nasal mucosa in man and in the cat using the techniques described by Jabonero, Champy Maillet and Koelle-Friedenwald. The most striking finding was the presence of microganglia deep within the mucosa of the inferior turbinate close to the glands. These microganglia were cholinergic in nature since they demonstrated a positive reaction to anticholinesterase. From this we deduce that the nasal parasympathetic pathway has its postganglionic neurones not only in the pterygopalatine ganglion but also in these microganglia of the inferior turbinate. Each of four groups of cats were submitted to different techniques, including administration of neostigmine, inferior turbinectomy and Vidian neurectomy. Resection of the microganglia by means of turbinectomy reduced the hypersecretion caused by neostigmine and this was most noticeable when a Vidian neurectomy was carried out in addition.

Galan Cortes JG; Perez Casas A; Suarez Nieto C.

Clin Otolaryngol 8703; 11(5):373-82

Animal; Human; Otorhinolaryngologic Diseases/*.

Oto-rhino-laryngological Research Society. London, October 1985. Abstracts.

JOURNAL ARTICLE.

The classical concept of the autonomic innervation of the nasal mucosa states that the postganglionic sympathetic neurones lie in the superior cervical ganglion and those of the postganglionic parasympathetic neurones are in the pterygopalatine ganglion. We have carried out a study of the fine structure of the respiratory nasal mucosa in man and in the cat using the techniques described by Jabonero, Champy Maillet and Koelle-Friedenwald. The most striking finding was the presence of microganglia deep within the mucosa of the inferior turbinate close to the glands. These microganglia were cholinergic in nature since they demonstrated a positive reaction to anticholinesterase. From this we deduce that the nasal parasympathetic pathway has its postganglionic neurones not only in the pterygopalatine ganglion but also in these microganglia of the inferior turbinate. Each of four groups of cats were submitted to different techniques, including administration of neostigmine, inferior turbinectomy and Vidian neurectomy. Resection of the microganglia by means of turbinectomy reduced the hypersecretion caused by neostigmine and this was most noticeable when a Vidian neurectomy was carried out in addition.

Galan Cortes JG; Perez Casas A; Suarez Nieto C.

Clin Otolaryngol 8703; 11(5):389-95

Adult; Animal; Anti-Inflammatory Agents, Non-Steroidal/AD; Crystallization; Drug Interactions; Female; Human; Hydrogen-Ion Concentration; Kidney/*DE; Male; Middle Age; Rats; Triamterene/AD/*AE/UR; Urine/*DE.

Triamterene-induced crystalluria and cylinduria: clinical and experimental studies.

JOURNAL ARTICLE.

We examined the occurrence of crystals and casts in the urine of healthy subjects after administration of triamterene and the site of crystal formation in experimental animals. Twenty out of twenty healthy subjects had abundant triamterene crystals and casts in acid urine after receiving a single 100 mg dose. Casts were present in the urine from 2-11 hours after administration of the diuretic. Cast formation occurred in acidic urine and was prevented by alkalinization of the urine with potassium citrate. Animal studies showed that crystallization and cast formation occurred in the medullary and papillary collecting ducts of the rat kidney. These findings provide a possible explanation for the reported nephrotoxicity of triamterene, particularly when given to patients who are receiving non-steroidal anti-inflammatory agents.

Fairley KF; Woo KT; Birch DF; Leaker BR; Ratnaike S.

Clin Nephrol 8703; 26(4):169-73

Age Factors; Biopsy/*/AE; Hematuria/ET; Human; Infant; Infant, Newborn; Kidney/*PA; Kidney Diseases/PA.

Percutaneous renal biopsy in infants and young children.

JOURNAL ARTICLE.

Records of 55 percutaneous renal biopsies performed in 53 children aged 5 days to two years were reviewed. Radiographic or ultrasound imaging techniques were not utilized during the biopsy procedure. Forty-nine of 55 biopsy attempts yielded sufficient tissue for histologic evaluation (89.1%). Transient gross hematuria not requiring intervention was the sole complication and was noted in 6 of 55 biopsy attempts (10.9%). Percutaneous renal biopsy can be performed safely in very young children and the success of the procedure is comparable to that in older children.

Sweet M; Brouhard BH; Ramirez-Seijas F; Kalia A; Travis LB.

Clin Nephrol 8703; 26(4):192-4

Antithrombin III/AN; Blood Proteins/AN; Comparative Study; Female; Fibrin/*; Fibrinogen/*AN; Fibrinopeptides A/*AN/BL; Heparin/*AD/AN; Human; Male; Peritoneal Cavity/*; Peritoneal Dialysis, Continuous Ambulatory/*AE.

Intraperitoneal fibrin-formation and its inhibition in CAPD.

JOURNAL ARTICLE.

The intraperitoneal fibrin formation and its inhibition by intraperitoneal heparin (5000 U) was investigated in six patients on CAPD. The intraperitoneal heparin concentration decreased linearily from 1.78 U/ml to 1.13 U/ml during a 4-hour dwell time. The antithrombin III-concentration increased to 0.56 +/- 0.1 mg/dl, reaching 1.87% of normal plasma values. The antithrombin III-portion of total protein was 0.62% in plasma and 0.79% in dialysate. The fibrinopeptide A-concentration, a specific product of thrombin action on fibrinogen was 37.1 +/- 11.8 ng/ml in plasma (normal range: less than 2.5 ng/ml) and 153.4 +/- 16.8 ng/ml in dialysate during regular CAPD. After the addition of 5000 U heparin the fibrinopeptide A-concentration in dialysate decreased to 11.6 +/- 2.6 ng/ml during a 4-hour dwell time. In vitro experiments showed no remarkable inhibition of fibrin formation by heparin without antithrombin III in dialysate. We suggest that the fibrinopeptide A is produced intraperitoneally and the antithrombin III-concentration in dialysate is sufficient to inhibit the fibrin formation after acceleration by heparin.

Gries E; Paar D; Graben N; Bock KD.

Clin Nephrol 8703; 26(4):209-12

Aged; Aged, 80 and over; Case Report; Female; Glomerulonephritis/*CI/DI; Human; Ketoprofen/*AE; Nephrotic Syndrome/*CI/DI; Osteoarthritis/DT; Phenylpropionates/*AE.

Reversible membranous glomerulonephritis associated with ketoprofen.

JOURNAL ARTICLE.

An 87-year-old woman presented with the nephrotic syndrome 12 months after administration of ketoprofen, 100 mg daily for osteoarthritis. Clinical course and laboratory data were consistent with drug-induced nephropathy. Kidney biopsy showed membranous glomerulonephritis. Evolution was favorable with resolution of proteinuria after drug withdrawal and steroid administration. A review of the literature on nephrotic syndrome associated with NSAID reveals membranous glomerulonephritis to be an unusual complication.

Sennesael J; Van den Houte K; Verbeelen D.

Clin Nephrol 8703; 26(4):213-5

Adolescence; Case Report; Cervical Vertebrae/*SU; Female; Follow-Up Studies; Human; Osteoma, Osteoid/*DI/SU; Spinal Neoplasms/*DI/SU.

Osteoid osteoma in a cervical pedicle. Resection via transpillar approach.

JOURNAL ARTICLE.

Lesions in the pedicles of the cervical spine are both a diagnostic and technical challenge. An osteoid osteoma of the pedicle of the fourth cervical vertebra occurred in a 17-year-old girl. Resection of the tumor adjacent to the dura medially and the vertebral artery anterolaterally was accomplished via a transpillar approach. The transosseus approach preserved the facet joints and posterior elements and obviated the need for an interbody fusion.

Hershman E; Bjorkengren AJ; Fielding JW; Allen SC.

Clin Orthop 8703; (213):115-7

Adolescence; Adult; Elbow Joint/*IR; Human; Laterality; Movement; Muscles/*IR; Proprioception/*; Scoliosis/*ET/PP.

Upper extremity proprioception in idiopathic scoliosis.

JOURNAL ARTICLE.

Twenty-three patients with idiopathic scoliosis were tested for upper extremity proprioceptive function. All subjects had documented progression of deformity, with an average curvature of 34 degrees. The average ages for scoliotics and 18 control subjects were 16.1 and 20.8 years, respectively. Controls had no spinal deformity and underwent identical test procedures. The test results showed that scoliotic subjects had significant asymmetry between right and left limbs in their threshold for detection of joint motion (p less than or equal to 0.005) and in their ability to reproduce angles to which their elbow joint had been previously positioned (p less than or equal to 0.025). Slight asymmetry also was observed in the reproduction tests of the control group (p less than or equal to 0.013); however, there was no significant asymmetry seen in this group for the threshold test. Performance of bilateral limbs was designated good and bad for both groups; the limb that performed better in proprioceptive function was designated good limb. Analysis of data showed that the scoliotics' good and bad limbs performed inferiorly in both threshold and angle reproduction tests when compared with normal controls. The results of this study imply, but do not localize, a neurologic deficit in scoliotic patients.

Cook SD; Harding AF; Burke SW; Whitecloud TS; Barrack RL; Leinhardt TM.

Clin Orthop 8703; (213):118-24

Adult; Ankle Joint/*IN/RA; Bone Nails/*; Follow-Up Studies; Fracture Fixation, Intramedullary/IS/*MT; Fractures/*SU; Human.

A new approach to the treatment of ankle fractures. The Inyo nail.

JOURNAL ARTICLE.

The Inyo nail is a new intramedullary device for the treatment of fractures of the distal fibula. It is a tapered V-shaped nail made of malleable stainless steel, which provides rigid fracture fixation. Torsional stress is resisted because of its triflanged shape. It may be introduced closed, using the image intensifier. Two groups of patients were evaluated: Group I was treated with the Inyo nail and Group II was treated by the Association For the Study of Internal Fixation (ASIF) technique. Eighty-five percent of the patients in Group I were rated as good, compared with 63% in Group II. There was significantly less morbidity and complications in Group I. Several factors must be observed in the treatment of ankle fractures. Stress radiographs must be obtained intraoperative. Surgery may be indicated in unstable supination lateral rotation Type II injuries, if these occur in patients with high physical demands. Anatomic reduction of the lateral malleolus must be obtained. Early weight-bearing and motion produces the best result. Late reconstruction of malunions can be accomplished using the Inyo nail.

McLennan JG; Ungersma JA.

Clin Orthop 8703; (213):125-36

Adolescence; Athletic Injuries/RH/*TH; Braces; Football/*; Human; Immobilization; Knee Injuries/RH/*TH; Ligaments/*IN; Prospective Studies; Time Factors.

Nonoperative management of isolated grade III collateral ligament injury in high school football players.

JOURNAL ARTICLE.

In a prospective study, 24 high school football players with isolated Grade III injuries of the medial collateral ligament (MCL) of the knee were treated by conservative management. This included an active rehabilitation program, progressing from immobilization and controlled motion in an orthotic rehabilitation knee brace, to muscle strengthening and agility exercise. A stable knee was achieved in 22 cases; the average recovery time was 29 days. The athletes returned to competitive sports at a mean time of 34 days. These results confirm previous reports of successful nonoperative management of isolated Grade III MCL injuries.

Jones RE; Henley MB; Francis P.

Clin Orthop 8703; (213):137-40

Aged; Female; Follow-Up Studies; Human; Knee Joint/*RA; Knee Prosthesis/*; Male; Photogrammetry/MT; Statistics; Tibia/RA.

Tibial component fixation in knee arthroplasty.

JOURNAL ARTICLE.

Using roentgen stereophotogrammetric analysis (RSA), the integrity of the bond between the tibial component and the tibia was studied in seven knees, implanted with a cemented Kinematic total knee prosthesis for gonarthrosis. Migration ranging from 0.3 to 1.9 mm over a two-year period occurred in all seven cases. Displacement, induced by external forces, ranging from 0.2 to 1.0 mm was observed in five cases. Measurable migration and inducible displacement may be the rule rather than an exception in total knee arthroplasty (TKA). Accordingly, absolute rigid fixation would not be necessary for successful function of a TKA.

Ryd L; Lindstrand A; Rosenquist R; Selvik G.

Clin Orthop 8703; (213):141-9

Adult; Aged; Casts, Surgical; Evaluation Studies; Female; Femur/PP; Human; Knee Injuries/PP/*TH; Knee Joint/PP/*RA; Male; Middle Age; Patella/PP; Rupture; Tendons/PP.

Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation.

JOURNAL ARTICLE.

The functional results of 28 cases of rupture of the quadriceps and patellar tendons are reported. Excellent or good results were noted in 15 of 18 quadriceps and 7 of 10 patellar tendons. Radiographic comparison with the opposite knee disclosed incongruences between the patella and the femoral groove in the tangential view and/or cranial-caudal position of the patella in the lateral view in 13 of the quadriceps tendon ruptures and seven of the patellar tendon ruptures. Patients with residual pain had patellofemoral incongruity but since two-thirds of the patients with incongruity were asymptomatic, incongruity alone may not be the cause of the symptoms. There was no positive correlation to muscular strength or range of movement. Nevertheless, exact adaptation of the patellar tendon and periarticular tissue seems necessary to obtain correct patello-femoral articulation. Reinforcement of the tendon with a wire cerclage is recommended to decrease the tension on the suture line and the consequent risk of a secondary rupture. In acute ruptures of the quadriceps tendon end-to-end sutures are sufficient.

Larsen E; Lund PM.

Clin Orthop 8703; (213):150-3

Adult; Child; Human; Implants, Artificial; Knee; Ligaments/*SU; Orthopedic Equipment/*; Orthopedics/*MT; Polyethylene Terephthalate; Prosthesis.

A modified technique for anterior cruciate ligament (ACL) surgery using a new drill guide for isometric positioning of the ACL.

JOURNAL ARTICLE.

In reconstructing the anterior cruciate ligament (ACL) it is important to place the inner ends of the drill channels correctly, to get the ACL into an isometric position. Anatomic studies demonstrate the value of a modified surgical technique using a special drill guide for standardized positioning of the anterior cruciate substitute. The drill guide consists of a metal frame with one adjustable and one fixed guide tube. Drilling is done from the anteromedial aspect of the tibia, upwards, through the joint space and the femur in a straight line, both channels being drilled in a single procedure. The precision of guided drilling was superior to that of free-hand drilling in positioning the ligament in the correct anatomic place.

Odensten M; Gillquist J.

Clin Orthop 8703; (213):154-8

Adolescence; Bone Diseases, Developmental/*CO; Dislocations/*ET/RA; Female; Femur/GD; Human; Knee Joint/RA; Male; Mathematics; Patella/*GD/RA; Retrospective Studies.

Patella alta and the adolescent growth spurt.

JOURNAL ARTICLE.

The presence of patella alta has been linked to recurrent dislocation of the patella and the patello-femoral stress syndrome. It is not known whether patella alta is an inherited or acquired trait. To investigate the relationship of patella during the adolescent growth spurt, serial orthoroentgenograms (growth study films) were retrospectively analyzed in 19 patients. Two were found in whom proximal patella migration could be correlated (r = 0.85) with femoral growth rate. This was significant at the p = 0.01 level. Girls had a higher correlation of patella height to growth rate than boys. In certain cases, patella alta is an acquired rather than inherited condition; this supports the theory that overgrowth during the growth spurt can lead to patella alta in some individuals.

Micheli LJ; Slater JA; Woods E; Gerbino PG.

Clin Orthop 8703; (213):159-62

False Negative Reactions; Human; Knee Injuries/*DI; Knee Joint/*PP; Ligaments/IN; Movement; Physical Examination/MT; Support, Non-U.S. Gov't; Tibia/*PP.

Accurate interpretation of the Lachman test.

JOURNAL ARTICLE.

In a consecutive series of patients with knee complaints, tibial rotation consistently affected the interpretation of the Lachman test (passive anterior tibial translation in slight knee flexion). To perform the Lachman test correctly, the anterior tibial force must be applied posteromedially on the proximal tibia. This is best achieved by having the leg under examination on the same side of the bed as the examiner, and with slight external tibial rotation. Reaching across the bed to examine either leg can create either false positive or false negative Lachman results due to inadvertent tibial rotation (internal tibial rotation decreases translation) and inaccurate comparisons of the injured and normal legs. The importance of tibial rotation must be recognized if the Lachman test is to be used reliably and with maximum sensitivity.

Frank C.

Clin Orthop 8703; (213):163-6

Exertion; Fractures/EP/*RI/TH; Human; Male; Military Personnel/*; Pain/ET/*RI; Physical Education and Training; Prospective Studies; Technetium Tc 99m Medronate/DU; Tibia/*IN/RI.

Medial tibial pain. A prospective study of its cause among military recruits.

JOURNAL ARTICLE.

In a prospective study of 295 infantry recruits during 14 weeks of basic training, 41% had medial tibial pain. Routine scintigraphic evaluation in cases of medial tibial bone pain showed that 63% had abnormalities. A stress fracture was found in 46%. Only two patients had periostitis. None had ischemic medial compartment syndrome. Physical examination could not differentiate between cases with medial tibial bone pain secondary to stress fractures and those with scintigraphically normal tibias. When both pain and swelling were localized in the middle one-third of the tibia, the lesion most likely proved to be a stress fracture.

Milgrom C; Giladi M; Stein M; Kashtan H; Margulies J; Chisin R; Steinberg R; Swissa A; Aharonson Z.

Clin Orthop 8703; (213):167-71

Double-Blind Method; Exudates and Transudates/DE; Follow-Up Studies; Human; Injections, Intra-Articular; Knee Joint/PP/*SU; Methylprednisolone/*AA/TU; Movement/DE; Pain/PC; Support, U.S. Gov't, Non-P.H.S..

Intraarticular methylprednisolone acetate in knee arthrotomy.

JOURNAL ARTICLE.

Ninety-eight arthrotomy patients undergoing meniscectomy were given intraoperative intraarticular methylprednisolone (40 mg) or placebo using double-blind technique and were evaluated clinically at three days, two weeks, four weeks, eight weeks, and twelve weeks after operation. Patients who received methylprednisolone showed small but statistically significant accelerated rehabilitation time with respect to subjectively evaluated pain and range of motion, through two weeks after operation. After two weeks, there was no further advantage over placebo through 12 weeks of rehabilitation.

Whittaker RP; Menkowitz E; Becker D.

Clin Orthop 8703; (213):172-6

Adult; Aged; Female; Femur/RA; Human; Knee Joint/*RA; Male; Middle Age; Osteoarthritis/PA/*RA; Tibia/*RA; Tomography, X-Ray Computed; Torsion.

Tibial torsion in patients with medial-type osteoarthritic knee.

JOURNAL ARTICLE.

Computed tomography measurements of tibial torsion were evaluated in 85 patients with medial-type osteoarthritic knees and in 24 normal adults. Although there were no differences in the degrees of femoral torsion or knee joint rotation, external tibial torsion was observed to have a mean value of 11.3 degrees, significantly smaller than the 23.5 degrees observed in the normal adults (p less than 0.01). The more advanced the osteoarthritic stage, the greater was the reduction in external tibial torsion. Reduction of external torsion of the tibia was most severe at the proximal tibial metaphysis.

Yagi T; Sasaki T.

Clin Orthop 8703; (213):177-82

Adult; Bone Screws; Case Report; Femoral Fractures/*SU; Femoral Neck Fractures/SU; Fluoroscopy; Fracture Fixation, Internal/*; Fracture Fixation, Intramedullary; Hip Fractures/SU; Human; Male.

Ipsilateral femoral neck and shaft fractures. Report of two cases using an alternate technique.

JOURNAL ARTICLE.

A technique for ipsilateral femoral neck and shaft fracture using the sliding compression hip screw with plate combined with trochanteric antegrade Ender nailing of the femur was applied in two cases. Ender nails can be passed without difficulty past a compression hip screw and the bicortical plating screws. The hip and femur can be fixed internally through a single approach in a single position. Sliding compression hip screw devices can provide excellent preliminary stable femoral neck fixation. Blood supply to the femoral head is not disturbed while the femoral intramedullary fixation is performed. Antegrade Ender nailing avoids the common knee complications associated with other retrograde techniques. Decreased operative time, less blood loss, less technical difficulty, and early mobilization are important factors in the multiple-injured patient. Femoral intramedullary fixation may require open reduction, circlerage to ensure stability, and maintenance of alignment in case of significant comminution to allow early crutch ambulation. This mode of fixation may be advantageous for selected cases.

Harryman DT 2d; Kurth LA; Davis CM.

Clin Orthop 8703; (213):183-8

Bone Cements/AE; Bone Resorption/PA/*RA; Case Report; Follow-Up Studies; Hip Joint/PA/*RA; Hip Prosthesis/*AE; Human; Male; Middle Age; Osteoarthritis/RA; Reoperation.

14-year follow-up study of a patient with massive calcar resorption. A case report.

JOURNAL ARTICLE.

The authors present an in-depth clinical, radiographic, and pathologic analysis of a 62-year-old man with massive bone reabsorption around the proximal femur in a total hip arthroplasty (THA). The THA was revised 13 years after implantation. Thirty millimeters of calcar resorption was noted radiographically. Evidence of stem bending was present on examination of the femoral implant, and marked wear of the acetabular cup was noted. The pathologic evaluation of removed calcar bone and cement revealed a histiocytic mass invading the bone. Intracellular and extracellular polymethylene debris was noted within the invasive mass. Evidence of fragmented methylmethacrylate cement was also present. The bone-cement interface in the excised calcar region contained segments that showed active bone remodelling around the cement without an interposed membrane. It is possible that this case of calcar resorption began with histiocytic activation and recruitment by polyethylene wear debris followed by active bone lysis. The process may be perpetuated by the fragmentation of cement, as motion occurred at the calcar bone-cement interface, and may represent an extreme example of a process occurring in cases of calcar resorption in general.

Johanson NA; Callaghan JJ; Salvati EA; Merkow RL.

Clin Orthop 8703; (213):189-96

Adolescence; Adult; Case Report; Follow-Up Studies; Human; Male; Osteochondritis/*SU; Osteochondritis Dissecans/RA/*SU; Osteotomy/MT; Talus/*SU.

Closed percutaneous drilling for osteochondritis dissecans of the talus. A report of two cases.

JOURNAL ARTICLE.

Two cases of osteochondritis dissecans of the talar dome treated by closed percutaneous drilling are presented to illustrate a procedure for high-risk patients. The operation is performed with the aid of an image intensifier. The ostoechondral fragment is percutaneously drilled to avoid open operation and osteotomizing the medial malleolus.

Gepstein R; Conforty B; Weiss RE; Hallel T.

Clin Orthop 8703; (213):197-200

Acetabulum/RA; Adolescence; Adult; Bone Diseases, Developmental/*CO/RA; Case Report; Epiphyses, Slipped/RA; Female; Femur Head/RA; Femur Neck/RA; Follow-Up Studies; Hip Joint/GD/*RA; Human; Legg-Perthes Disease/RA; Male; Middle Age; Osteoarthritis/*ET/RA/SU.

Etiology of osteoarthritis of the hip.

JOURNAL ARTICLE.

More than 90% of patients with so-called primary or idiopathic osteoarthritis of the hips in whom sufficient data were available to make an assessment of the normality of the hip joint at the cessation of growth clearly showed demonstrable abnormalities in the hip joint. The most common are mild acetabular dysplasia and/or pistol grip deformity. This latter deformity is associated with mild slipped capital femoral epiphysis (recognized or unrecognized at the time), Legg-Perthes' disease (recognized or unrecognized at the time), multiple epiphyseal dysplasia, spondyloepiphyseal dysplasia, and/or the presence of an intraacetabular labrum, as well as, in certain instances, acetabular dysplasia. When these abnormalities are taken in conjunction with the detection of other metabolic abnormalities that can lead to osteoarthritis of the hip and which may not be recognized readily, such as hemochromatosis, ochronosis, calcium pyrophosphate disease, and monarticular rheumatoid arthritis, it seems clear that either osteoarthritis of the hip does not exist at all as a primary disease entity or, if it does, is extraordinarily rare.

Harris WH.

Clin Orthop 8703; (213):20-33

Aged; Bone Wires; Calcaneus/*SU; Case Report; Dislocations/ET/*SU; Female; Fractures/*SU; Human; Male; Middle Age.

Fracture dislocation of the calcaneus. A report of two cases.

JOURNAL ARTICLE.

In two typical cases of calcaneal fracture dislocation, the primary fracture, which runs forward and medially from a point behind the sustentaculum tali, is associated with inversion of the hindfoot. The calcaneus splits into a small anteromedial and a larger posterolateral fragment. Rupture of the lateral collateral ligament allows the posterolateral calcaneal fragment to move laterally to lie immediately subjacent to the distal fibula. Closed reduction is impossible. Open reduction of this rare fracture dislocation is essential. A lateral approach to the calcaneus is generally sufficient, but a second medial incision may be required.

Court-Brown CM; Boot DA; Kellam JF.

Clin Orthop 8703; (213):201-6

Adult; Case Report; Follow-Up Studies; Human; Immobilization; Male; Synostosis/*RA/RI; Ulna Fractures/*RA/TH.

Radioulnar synostosis following an isolated fracture of the ulnar shaft. A case report.

JOURNAL ARTICLE.

In the case of a 19-year-old man, overuse of his nondominant forearm resulted in a radioulnar synostosis. Despite the persistence of the synostosis, the patient adapted to loss of forearm rotation. No further treatment was necessary. Isolated fractures of the ulnar shaft are slow in healing. Several authors observed that early function may be beneficial. However, excessive activity causing motion at the fracture site may cause subperiosteal hemorrhage and soft tissue trauma and may stimulate exuberant callus formation. Fractures of the ulnar shaft, even undisplaced, need to be immobilized to prevent overuse.

Posman CL; Little RE.

Clin Orthop 8703; (213):207-10

Adult; Aged; Backache/*DT/ET; Female; Follow-Up Studies; Human; Injections, Intra-Articular; Lidocaine/TU; Male; Metrizamide/AD; Middle Age; Spinal Diseases/*DT/PA/RA.

Facet joint degeneration as a cause of low back pain.

JOURNAL ARTICLE.

Recognizing that not all patients with low back pain have lumbar disc disease, the authors began to inject facet joints in June 1982 and have experience now with 21 patients, each injected under fluoroscopic control with a mixture of local anesthetic and steroid. One technical problem occurred when large osteophytes blocked access to the facet joints. Otherwise, there were no complications and minimal morbidity. Most patients (15 of 20; 75%) had an initial response, but a much smaller number (six of 18 followed more than three months; 33%) had a lasting response. Repeat injections, when done, always led to temporary improvement but rarely to lasting relief (one of five; 20%). Three factors characterized the patients: a negative screening examination for other causes of back pain or sciatica; back pain with tenderness localized over one or more facet joints; and radiologic changes of degenerative joint disease within the facet joints. Facet joint disease may be a significant cause of low back pain. The above three criteria are useful in clinical identification of patients with this problem. Facet joint injections play an important role in the diagnosis and treatment of low back pain.

Lewinnek GE; Warfield CA.

Clin Orthop 8703; (213):216-22

Aged; Case Report; Chymopapain/*AE; Female; Follow-Up Studies; Human; Intervertebral Disk/*DE/PA/UL; Intervertebral Disk Chemolysis; Intervertebral Disk Displacement/RA/*SU; Prolapse; Support, U.S. Gov't, P.H.S.; Tomography, X-Ray Computed.

The effects of chymopapain on prolapsed human intervertebral disc. A clinical and correlative histochemical study.

JOURNAL ARTICLE.

Light and electron microscopy were used to demonstrate extensive matrix degradation in a failed chymopapain-treated disc as compared with an untreated degenerative control disc. Both specimens contained viable cells with patches of degenerative cells. There was a loss of disc height in the chymopapain-treated disc, but no improvement of symptoms. These results illustrated that even in well-circumscribed cases with documented disc protrusion into the spinal canal, the disc space narrowing following injection may aggravate the symptoms of nerve root entrapment, especially if a low-grade lateral recess stenosis is associated with the disc protrusion. The persistence or aggravation of symptoms probably is related to these anatomic considerations. The low level of enzyme activity in the injected area may or may not be correlated with the clinical response to treatment.

Suguro T; Oegema TR Jr; Bradford DS.

Clin Orthop 8703; (213):223-31

Adult; Case Report; Female; Follow-Up Studies; Fractures/*RA/TH; Human; Immobilization; Osteopetrosis/CO/*RA; Spinal Injuries/ET/*RA.

Stress fracture of the vertebral arch in osteopetrosis.

JOURNAL ARTICLE.

Stress fracture of the fourth vertebral arch occurred in a 21-year-old woman with a benign osteopetrosis. The fracture healed in three months after application of a body cast. It seems likely that the osteopetrotic bone resists force, in parallel with the cortical layer, but is fragile to forces at right angles to the plane of the cortical layer.

Suzuki S; Awaya G.

Clin Orthop 8703; (213):232-6

Accidents, Traffic; Adolescence; Adult; Female; Follow-Up Studies; Fracture Fixation, Internal/AE; Human; Male; Middle Age; Spinal Cord Injuries/*CO; Tibial Fractures/*CO/SU/TH.

The management of tibial fractures in acute spinal cord injury patients.

JOURNAL ARTICLE.

Of 34 tibia fractures in 28 acute spinal cord injuries, 13 patients had complete and 15 had incomplete neurologic lesions. Tibia fractures were divided into three groups: Group I, nonoperative treatment; Group II, early open reduction and internal fixation; and Group III, Type III open injuries. Group I included 17 fractures, of which nine (53%) had delayed union, malunion, or nonunion. The average time to union was 6.5 months. Seven patients had pressure sores and pulmonary emboli. Eleven fractures were noted in Group II. One delayed union (9%), one superficial wound infection that healed uneventfully, and one deep vein thrombosis were noted. The average time to union was 12 weeks. All six Group III tibias had delayed and nonunions, regardless of treatment. Nonoperative fractures healed at a prolonged rate, while open reduction and internal fixation enhanced the rate and time to union. Fractures treated with early open reduction and internal fixation, excluding Group III patients, had the least orthopedic and medical complications. Open reduction and internal fixation is a justifiable alternative to nonoperative treatment in the uncomplicated tibia fracture regardless of neurologic lesion for improved medical and fracture care.

Garland DE; Saucedo T; Reiser TV.

Clin Orthop 8703; (213):237-40

Adolescence; Adult; Comparative Study; Female; Follow-Up Studies; Human; Knee Joint/*SU; Male; Middle Age; Orthopedics/AE/*MT; Osteoarthritis/*SU; Patella/SU; Postoperative Complications/*SU; Reoperation.

The Maquet procedure--anterior displacement of the tibial tubercle. Indications, contraindications, and precautions.

JOURNAL ARTICLE.

Maquet recommended 2-2.5 cm of anterior tibial tubercle elevation for patients with symptomatic osteoarthrosis of the patellofemoral joint. Fifty-three patients with osteoarthrosis were divided into three groups. The first 12 patients were treated by the classical Maquet procedure; 11 were totally relieved of patellofemoral pain, but there was one failure and five complications. In the second group of 32 patients, the patella was realigned within its groove to alter tracking of the patella to the proximal femoral condyles when necessary. Fish-mouthing technique and insertion of a drain after surgery were done. After a two-year follow-up examination, there were two failures and five complications. A third group of nine patients was treated with Ferguson's modification of Maquet's operation using a 1.25-cm tibial tubercle elevation through a transverse incision; two of the nine had complications, subsequently treated successfully by converting Ferguson's operation into the Maquet operation, as modified for Group II. The modified Maquet procedure can be an effective and reliable treatment of patellofemoral arthrosis with a relatively low incidence of complications.

Radin EL.

Clin Orthop 8703; (213):241-8

Achilles Tendon/*IN/SU; Adult; Case Report; Female; Follow-Up Studies; Human; Rheumatic Fever/DT; Rupture; Steroids/AE; Tendon Injuries/PC.

Bilateral simultaneous achilles tendon ruptures. A case report and review of the literature.

JOURNAL ARTICLE.

Bilateral simultaneous Achilles tendon ruptures are rare, with only ten cases reported in the English literature. Our case is that of a 44-year-old woman, along with a review of the literature. Affected persons usually are on chronic steroid treatment and in the fifth to seventh decades of life. The patient may have concomitant systemic disease, and the injury occurs with relatively mild trauma. The goals of treatment are mainly preventative, i.e., cessation of steroids as soon as possible and protective bracing of the remaining intact Achilles tendon.

Price AE; Evanski PM; Waugh TR.

Clin Orthop 8703; (213):249-50

Animal; Bone Marrow/*ME/PA/UL; Cell Differentiation; Cells, Cultured; Collagen/BI; Electron Probe Microanalysis; Hematopoietic Stem Cells/ME; Hydroxyapatites/BI; Male; Microscopy, Fluorescence; Minerals/*ME; Osteogenesis; Rabbits.

Mineralization in in vitro cultures of rabbit marrow stromal cells.

JOURNAL ARTICLE.

Localized regions of mineralization were found in confluent cultures of rabbit marrow fibroblastic cells. The mineralized tissue developed within clusters of giant fat cells in the spaces between the cells. Investigations with light and electron microscopy demonstrated that in these sites there was some differentiation of the fibroblastic cells in an osteogenic direction, shown by changes to more polygonal shapes, and the synthesis of well-banded collagen similar to that found in bone tissue. Differentiation may be due, in part, to increased cell density in a confined space. Growth of the mineralized tissue was observed in the living cultures with a fluorescence microscope. Electron probe microanalysis confirmed that the mineral formed was hydroxyapatite. Initiating sites of mineralization included membranous vesicular bodies, lipid, and products of cellular degeneration. Once initiated, mineralization appeared to spread rapidly into adjacent collagenous and other structures, suggesting the appearance of a mixture of skeletal-type and dystrophic mineralization.

Howlett CR; Cave J; Williamson M; Farmer J; Ali SY; Bab I; Owen ME.

Clin Orthop 8703; (213):251-63

Biomechanics; Bone Regeneration; Bone Resorption; Human; Ilium/PA/*PP; Models, Biological; Osteoporosis/DT/PA/*PP; Probability/*; Stochastic Processes/*.

A stochastic analysis of iliac trabecular bone dynamics.

JOURNAL ARTICLE.

Published normal histomorphometric data were used to derive distributions of thicknesses of trabecular plates and completed bone remodelling units (the basic multicellular unit carrying out bone remodelling, the BMU, when completed is termed a structural unit BSU). A stochastic model was set up to investigate the predictions of current BMU theory. Each of 100 trabecular "thicknesses" was drawn from the appropriate normal distribution using a pseudorandom number generator. Each day, each of its two surfaces when quiescent was assumed to have a 1:900 chance of initiating a remodelling cycle. Resorption (active, 12 days; reversal phase, 27 days) was followed by formation (94 +/- 35 days) and resulted in BMU balance when resorption depth was 36.8 +/- 9.2 micron. Fenestration (thickness less than 0) was assumed to lead to permanent loss of the trabecula. The original model unrealistically increased its mean trabecular thickness as thin trabeculae were lost. This was corrected by assuming that thin trabeculae had greater osteoblastic stimulation and a consequent tendency to thicken, perhaps due to higher mechanical loading. Over 20 years, 14% of trabeculae were lost when the BMU balance was exact and the distribution of trabecular thicknesses was unchanged. About one-half of fenestrations were due to deeper-than-average resorption cavities developing in thin trabeculae, and the remainder to coincident remodelling on both surfaces. A 10% fall in osteoblast lifespan resulted in an additional 36.7% loss of trabecular bone volume and mean trabecular thickness fell to 83.1 micron, compatible with Courpron's data. Simulating more rapid mechanisms of bone loss, approximately 50% of trabeculae could be lost after ten years by the arrest of bone formation; the doubling of resorption depth with unchanged bone formation; and a doubling in the rate of initiation of new BMUs with unchanged bone formation rate, all three followed by complete recovery of BMU balance after only two years. In each case, mean trabecular thickness fell only transiently but trabeculae continued to be lost after recovery. Prolonged osteoblast life span was the most likely explanation for the increased mean trabecular thicknesses and trabecular bone volumes seen in patients with osteoporosis, when treated with sodium fluoride plus calcium supplements or daily injections of parathyroid peptide hPTH 1-34.

Reeve J.

Clin Orthop 8703; (213):264-78

Adolescence; Bone Neoplasms/*SC/SU; Carcinoma/*SC/SU; Case Report; Combined Modality Therapy; Female; Follow-Up Studies; Human; Neoplasm Recurrence, Local/SU; Radius/*SU; Sella Turcica/SU; Skull Neoplasms/RT/SU; Tibia/*SU.

Evolution of a case of multicentric giant cell tumor over a 23-year period.

JOURNAL ARTICLE.

A 17-year-old girl had a multicentric giant cell tumor originating in the sphenoid and sella turcica that was observed for 23 years. During the first 12 years, the same lesion also appeared in the right proximal tibia and left distal radius. Curettage of the tibial lesion and packing with processed bovine bone were followed by a chronic osteomyelitis with continued intermittent wound drainage. Curettage of the radial lesion and packing it initially with autogenous iliac bone graft and subsequently with methylmethacrylate bone cement were followed by local recurrences. The radial lesion eventually was eradicated by a segmental resection of the distal radius. The resulting bony defect was bridged with a bicortical autogenous iliac graft and stabilized with a bone plate to produce a painless solid wrist fusion. No further tumor recurrence has been noted for the past two years.

Wu KK; Ross PM; Mitchell DC; Sprague HH.

Clin Orthop 8703; (213):279-88

Animal; Bone and Bones/*PP; Cartilage, Articular/ME/*PP; Disease Models, Animal; Human; Osteoarthritis/*ET/PP; Proteoglycans/ME; Rabbits; Stress, Mechanical; Support, U.S. Gov't, P.H.S..

Role of subchondral bone in the initiation and progression of cartilage damage.

JOURNAL ARTICLE.

Osteoarthrosis is a physiologic imbalance, a "joint failure" similar to "heart failure," in which mechanical factors play a role. The initiation and progression of cartilage damage are distinct phenomena. One of the mechanisms of initiation may be a steep stiffness gradient in the underlying subchondral bone. Progression of cartilage lesions probably requires stiffened subchondral bone. In such situations, transverse stresses at the base of the articular cartilage could cause deep horizontal splits in that tissue. The most likely cause of subchondral stiffening in an otherwise congruent joint is repeated failure of the musculoskeletal peak dynamic force attenuation mechanisms. The health and integrity of the overlying articular cartilage depends on the mechanical properties of its bony bed. In certain models of osteoarthrosis, alterations of the bony bed occur before the cartilage changes and suggest that this can occur in clinical conditions. Stiffening of the subchondral bone also can effect joint conformation, which involves deformation of articular cartilage and bone to create maximum contact areas under load.

Radin EL; Rose RM.

Clin Orthop 8703; (213):34-40

Cartilage, Articular/IM; Case Report; Complement 3/AN; Female; Hip Joint/SU; Histocytochemistry; Human; IgA/AN; IgG/AN; IgM/AN; Inflammation/IM; Knee Joint/SU; Male; Middle Age; Osteoarthritis/*IM/PA/SU; Support, Non-U.S. Gov't; Synovial Membrane/*IM.

Immune pathology in polyarticular osteoarthritis.

JOURNAL ARTICLE.

Although osteoarthritis (OA) generally is considered a disorder of mechanical origin, the common occurrence of chronic mononuclear cell infiltrates in the synovium in conjunction with immunofluorescent evidence for immune-reactant products in cartilage of surgical case specimens (knees, hips, and peripheral joints) has suggested the local involvement of immune processes in the arthritis. Further, the findings of polyarthropathy in the majority of these cases have indicated the propensity for a systemic disorder. Wide variations were noted in both synovial and cartilage immune changes, quite different to those found in rheumatoid arthritis, along with the frequent asymptomatology of the many joints involved. These features, with and without other causative factors, suggest that immune reactions of local and/or systemic origin occur at times in a population at risk for joint degradation.

Cooke TD.

Clin Orthop 8703; (213):41-9

Animal; Cartilage, Articular/*DE/ME/PA; Disease Models, Animal; Estradiol/*PD; Female; Human; Male; Organ Culture; Osteoarthritis/*ME; Ovariectomy; Prostaglandins/BI; Proteoglycans/BI; Rabbits; Stains and Staining; Support, U.S. Gov't, P.H.S.; Tamoxifen/*PD.

Estrogens and osteoarthritis.

JOURNAL ARTICLE.

Clinical and laboratory observations suggest that a relationship exists between sex hormones and the development of osteoarthritis. The mechanisms whereby these hormones influence the pathophysiology of osteoarthritis have been explored. Tamoxifen, an estrogen antagonist, reduced erosive changes in meniscectomy-induced osteoarthritis in rabbits. By contrast, estradiol worsened it. There was no effect of either agent on the incidence of osteophytes in this model. Both estradiol and tamoxifen affected proteoglycan, prostaglandin, and proteoglycanase production by cartilage components. These observations suggest that cartilage is a sex hormone-sensitive tissue. This may have therapeutic implications in the future.

Rosner IA; Goldberg VM; Moskowitz RW.

Clin Orthop 8703; (213):77-83

Animal; Anti-Inflammatory Agents, Non-Steroidal/AE/*TU; Atrophy/ME; Cartilage, Articular/*DE/ME/PA; Dogs; Extracellular Matrix/ME; Hindlimb; Human; Immobilization; In Vitro; Inflammation/DT; Osteoarthritis/*DT/ME/PA; Pain/DT; Proteoglycans/ME; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.; Synovial Fluid/ME.

Nonsteroidal antiinflammatory drugs in treatment of osteoarthritis.

JOURNAL ARTICLE.

It is clear that some synovial inflammation occurs in joints affected by osteoarthritis (OA) and it is well recognized that many patients with OA experience a decrease in pain and joint stiffness following administration of salicylates or other nonsteroidal antiinflammatory drugs (NSAIDs). However, neither the extent to which synovitis contributes to the cartilage breakdown in OA nor the effects of chronic administration of NSAIDs on the natural history of OA in humans is known. Recent studies indicate that several NSAIDs, including salicylates, suppress proteoglycan synthesis in articular cartilage in vitro. The effect on OA cartilage is more marked than that on normal cartilage. Other studies show that salicylate feeding may suppress proteoglycan metabolism in degenerating cartilage in vivo, aggravating the decrease in proteoglycan content caused by the disease itself. However, no effect of salicylates on normal articular cartilage has been observed in vivo. In damaged cartilage the magnitude of NSAID-induced suppression of proteoglycan metabolism appears to be related inversely to the proteoglycan content of the tissue. In addition, the NSAIDs used in treatment of arthritis today may differ with respect to their in vivo effects on articular cartilage metabolism due, in part, to differences between the molar concentrations of these drugs in synovial fluid.

Brandt KD; Slowman-Kovacs S.

Clin Orthop 8703; (213):84-91

Attention; Attention Deficit Disorder with Hyperactivity/DI/*PX; Child; Female; Follow-Up Studies; Human; Language Development Disorders/PX; Male; Psychiatric Status Rating Scales; Social Behavior.

Pediatric management of nonpervasively "hyperactive" children.

JOURNAL ARTICLE.

Sixty-five children viewed by their teachers as hyperactive were evaluated as to whether they would benefit from stimulant medication. All underwent extensive neurodevelopmental and educational testing. Additional information was obtained from school and parent questionnaires and interviews. Children were not placed on medication unless they demonstrated characteristic impulsive, inattentive, and/or overactive behavior in two of three environments (home, school, clinic). Fifty-two children (80%) were not placed on medication. Follow-up was completed in 80 percent, and 93 percent of these children were doing well with nonpharmacologic interventions. Initial comparison of children not placed and placed on medication revealed that age, race, SES, amount of resource help and retention could not distinguish groups. Children placed on medication had difficulties earlier in school (chi 2 = 4.88, p less than 0.05), weren't as delayed academically (chi 2 = 6.30, p less than 0.05) and had less neurodevelopmental disorders (chi 2 = 9.01, p less than 0.01). If a careful psychosocial history does not reveal impulsive, inattentive, and/or hyperactive behavior outside of school, a child should be evaluated to rule out neurodevelopmental and educational problems.

Landman GB; McCrindle B.

Clin Pediatr (Phila) 8703; 25(12):600-4

Adolescence; Anxiety; Chest Pain/DI/*ET/PX; Child; Depression; Female; Follow-Up Studies; Headache/ET; Human; Male; Recurrence; Stress, Psychological/CO.

The natural history of idiopathic chest pain in children. A follow-up study.

JOURNAL ARTICLE.

Repetitive chest pain of obscure origin is commonly encountered in older children and adolescents. A questionnaire study was conducted to determine the long-term outcome in 31 patients diagnosed as having idiopathic recurrent chest pain after an average 4.1-year follow-up period. Although 45 percent reported having had persistent symptoms, chest pain had disappeared in 81 percent of those followed more than 3 years. Equally reassuring is the fact that in no case did occult disease subsequently appear to account for the initial symptoms. This study supports the current clinical approach of limited diagnostic evaluation and reassurance in the management of these patients.

Rowland TW; Richards MM.

Clin Pediatr (Phila) 8703; 25(12):612-4

Adolescence; Alcoholic Intoxication/BL/*EP; Blood Glucose/AN; Canada; Child; Child, Preschool; Electrolytes/BL; Female; Human; Hypoglycemia/ET; Infant; Male; Retrospective Studies.

Ethyl alcohol ingestion in children. A 15-year review.

JOURNAL ARTICLE.

Information on ethyl alcohol intoxication in children is scarce. A retrospective study was conducted by chart reviews of 27 patients with documented ethanol ingestion admitted to the Alberta Children's Hospital, Foothills Provincial Hospital, Calgary General Hospital or Holy Cross Hospital from 1969 to 1984. Six patients had hypoglycemia and one experienced a convulsion. The rate of alcohol elimination was found to be greater than 6.2 mM/L/hr (28.4 mg/dl/hr), approximately twice the rate seen in adults. Six patients had hypokalemia, and two had severe metabolic acidosis.

Leung AK.

Clin Pediatr (Phila) 8703; 25(12):617-9

Adolescence; Ambulances; Child; Child, Preschool; Emergency Medical Services/*; Female; Heart Arrest/EP/TH; Human; Infant; Intensive Care Units/*; Male; Mobile Health Units/*; Pediatrics; Prospective Studies; Resuscitation; Seizures/*EP/TH; Sudden Infant Death/*EP/TH.

Should the Mobile Intensive Care Unit respond to pediatric emergencies?

JOURNAL ARTICLE.

Between October 1982 and October 1985, the Mobile Intensive Care Unit (MICU) in Jerusalem responded to 625 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problem was seizures, diagnosed in 205 cases (33%). The second most frequent group related to trauma (175 cases; 28%). There were 71 cases (11.4%) of cardiac arrest. Resuscitation was attempted in 37, but there were no long-term survivors. Almost all cardiac arrest patients were found in asystole, and most had antecedent serious medical problems. Compared with the adult population, children were less likely to require or benefit from an advanced level of prehospital care. When resources for advanced care are limited, priority should be given to adult emergencies.

Applebaum D; Slater PE.

Clin Pediatr (Phila) 8703; 25(12):620-3

Bronchoscopy; Case Report; Child; Diagnosis, Differential; Female; Foreign Bodies/DI/*RA; Human; Infant; Male; Respiratory Tract Infections/DI; Thoracic Radiography/*; Trachea/*.

Normal radiographic findings after foreign body aspiration. When the history counts.

JOURNAL ARTICLE.

Foreign body aspiration in children is frequently associated with unilateral emphysema or atelectasis on chest x-ray. Two cases are reported of tracheal or bilateral foreign bodies in which the original chest x-rays were read as normal, but the history was suggestive of the foreign body aspiration. Early bronchoscopy can prevent the long-term morbidity that results from unrecognized tracheobronchial foreign bodies.

Musemeche CA; Kosloske AM.

Clin Pediatr (Phila) 8703; 25(12):624-5

Case Report; Human; Infant, Newborn; Infant, Premature, Diseases/*TH; Intubation, Intratracheal/*/MT; Male; Pulmonary Emphysema/*TH.

Endotracheal tube modification for therapy of right-sided pulmonary interstitial emphysema.

JOURNAL ARTICLE.

Foreign body aspiration in children is frequently associated with unilateral emphysema or atelectasis on chest x-ray. Two cases are reported of tracheal or bilateral foreign bodies in which the original chest x-rays were read as normal, but the history was suggestive of the foreign body aspiration. Early bronchoscopy can prevent the long-term morbidity that results from unrecognized tracheobronchial foreign bodies.

DeWitte DB; Batton DG; Prudent L; Maisels MJ.

Clin Pediatr (Phila) 8703; 25(12):626-8

Hemangioma, Cavernous/*PA; Human; Klippel-Trenaunay Disease/PA; Puberty/*; Skin Neoplasms/*PA.

Growth of cavernous hemangioma with puberty [letter]

LETTER.

Foreign body aspiration in children is frequently associated with unilateral emphysema or atelectasis on chest x-ray. Two cases are reported of tracheal or bilateral foreign bodies in which the original chest x-rays were read as normal, but the history was suggestive of the foreign body aspiration. Early bronchoscopy can prevent the long-term morbidity that results from unrecognized tracheobronchial foreign bodies.

Stickler GB.

Clin Pediatr (Phila) 8703; 25(12):629

Adolescence; Anorexia Nervosa/*DH; Body Weight; Caloric Intake/*; Diet/*; Human.

The food exchange system in the treatment of anorexia nervosa [letter]

LETTER.

Foreign body aspiration in children is frequently associated with unilateral emphysema or atelectasis on chest x-ray. Two cases are reported of tracheal or bilateral foreign bodies in which the original chest x-rays were read as normal, but the history was suggestive of the foreign body aspiration. Early bronchoscopy can prevent the long-term morbidity that results from unrecognized tracheobronchial foreign bodies.

Kreipe RE; Trott M.

Clin Pediatr (Phila) 8703; 25(12):629