Mechanisms of clozapine-induced agranulocytosis. The aetiology of clozapine-induced agranulocytosis remains unknown. Leading candidates include an immune mechanism that is possibly complement- or drug-dependent and a toxic mechanism. We analysed these mechanisms by culturing the granulocyte precursor stem cell from the bone marrow in the presence of patients' serum, clozapine or clozapine metabolites. Studies with patients' serum failed to identify an immune mechanism. On the basis of our preliminary data, it appears that a toxic mechanism may be responsible, and this is more likely to be due to a metabolite than to clozapine itself. Further studies are required to determine the sensitivity of bone marrow precursors to these clozapine derivatives. For instance, prospective collection of serum will make it possible to evaluate whether high metabolite concentrations develop in sensitive individuals and whether they are responsible for agranulocytosis. If such elevated levels occur, further studies will be required to determine whether prospective monitoring will effectively identify patients at risk and ultimately prevent the onset of agranulocytosis by early discontinuation of the drug.


Recent developments in the management of paracetamol (acetaminophen) poisoning. Paracetamol (acetaminophen) poisoning accounts for almost a third of admissions to our district poisons unit, and is the commonest cause of death in such patients. Antidotal treatment may be effective up to 10h after overdose with oral methionine or up to 24h with acetylcysteine (not 15h as previously suggested for the latter). Patients taking paracetamol overdose while also receiving drugs which induce hepatic enzymes are more susceptible to liver damage, and antidotal treatment may be necessary at lower plasma paracetamol concentrations (50% of the normal treatment line). As survival following liver transplantation is now increasing, it is important to identify early prognostic indicators in fulminant hepatic failure, so that those patients with a high chance of fatal outcome can be considered for transplantation. Useful indicators are the presence of acidosis, marked prolongation of prothrombin time or a continued rise in prothrombin time on day 4 after the overdose. There is no evidence that paracetamol or acetylcysteine are teratogenic in pregnancy. Delays in administering acetylcysteine after paracetamol poisoning in pregnancy have been shown to increase the risk of spontaneous abortion and fetal death. Thus, acetylcysteine should be started as early as possible where treatment is indicated.


Mutagenicity of quinolone antibacterials. The literature is summarised on the activity of quinolone antibacterial compounds in assays which are commonly used for risk assessment of new pharmaceuticals. These include assays for DNA damage, sister chromatid exchanges, chromosome aberrations and mutation induction. The general pattern of activity exhibited by these compounds is induction of DNA damage in both prokaryotic and eukaryotic cells, and induction of mutations in DNA repair-proficient bacteria and at the thymidine kinase locus in mammalian cells. They do not appear as a class to induce mutations at the hypoxanthine-guanine-phosphoribosyltransferase (HGPRT) or Na+,K(+)-ATPase loci or to cause chromosome aberrations. It is suggested that these actions may be the result of interference with eukaryotic topoisomerase and that this interference differs in some respects from the topoisomerase interference caused by certain antitumour compounds. The postulated mechanism of action has important implications for assessment of risk from consumption of quinolone antibacterials. The risk of adverse genotoxic events should vary directly with the concentration of drug reaching the intracellular enzyme target and the affinity of the drug for the target. Results of carcinogenicity studies conducted to date with the quinolone antibacterials suggest minimal risk from long term consumption of the newer, second-generation compounds.


Clinical experience of clozapine-induced neutropenia in the UK. Laboratory investigation using liquid culture systems and immunofluorocytometry. An incidence of drug-induced neutropenia of 2.5% has been found in the first 1000 patients to be treated with clozapine in the UK. The majority of affected patients experienced mild neutropenia (n = 22) with only 3 patients developing agranulocytosis. Data collected from these 25 patients suggest that the mechanism of neutropenia may be multifactorial. Laboratory investigation using liquid culture systems and immunofluorocytometry has identified clozapine and its major metabolite N-desmethyl clozapine as exhibiting toxic effects against myeloid maturation and myeloid mitotic compartments, respectively. Increased susceptibility to the toxic effects of clozapine was shown in 1 patient who had previously developed clozapine-associated neutropenia. No clinical or laboratory evidence of drug-induced antineutrophil or antimyeloid precursor antibodies was found.


Adverse reactions to drugs as a cause of admissions to a general teaching hospital in Hong Kong. To determine the pattern of and the risk factors for adverse drug reactions (ADRs) in Hong Kong, a prospective study of acute admissions to 2 general medical wards at the Prince of Wales Hospital was undertaken. Of the 1701 admissions included in this study, 74 (4.4%) were attributed to ADRs. Sulphonylureas, nonsteroidal anti-inflammatories (NSAIDs) and insulin accounted for 61% of cases. The most frequent ADRs were hypoglycaemia (43%) and gastrointestinal haemorrhage (29.7%). Both old age and impaired renal function appear to be important risk factors for ADRs. In such situations, careful dose adjustments, use of an alternative drug or total avoidance may be necessary. Particular attention should be given to oral hypoglycaemic drugs and NSAIDs.


Comparative risk-benefit assessment of drugs used in the management of hypertension in pregnancy. Antihypertensive treatment in pregnancy is needed to protect the mother from the dangers of severe hypertension (greater than or equal to 170/110mm Hg), particularly cerebral haemorrhage in the context of preeclampsia. There is no evidence that treatment of the hypertension confers any other benefit; the onset and progression of preeclampsia is neither prevented nor ameliorated. Therefore, there are no indications for treating mild-to-moderate hypertension (140 to 169/90 to 109mm Hg). Intravenous hydralazine and oral nifedipine are effective drugs to treat severe hypertension acutely, the latter having the advantage of ease of administration. For long term therapy, methyldopa is the only drug which has been fully assessed and shown to be safe for the neonate and infant. beta-Adrenoceptor antagonists are safe to use in the third trimester but cause significant intrauterine growth retardation when used for longer periods. ACE inhibitors are contraindicated and diuretics should be avoided. Although calcium antagonists appear to have much potential they require further assessment of their use in pregnancy.


No direct clinical relevance of the human leucocyte antigen (HLA) system in clozapine-induced agranulocytosis. The clinical use of clozapine in psychiatry is restricted by the associated risk of agranulocytosis. This risk is significantly higher than that associated with conventional antipsychotic medications. In order to identify a possible parameter to detect susceptible individuals before treatment, 103 patients with a history of clozapine-induced granulocytopenia or agranulocytosis and 95 matched control patients were typed for human leucocyte antigen (HLA)-A, -B, -C, -DR, -DQ and for a number of neutrophil-specific alloantigens. No significant association between certain HLA alleles or neutrophil antigens and susceptibility to clozapine-induced granulocytopenia or agranulocytosis was observed.


Adverse effects of local anaesthetics.

Adverse effects of local anaesthetics. Local anaesthetics are responsible for 5 to 10% of all reported adverse reactions to anaesthetic drugs. Adverse effects may be classified as: (a) those associated directly with blocking ion channels in cell membranes, such as cardiovascular and CNS toxicity; (b) those due to other effects of drug or vehicle (mainly peripheral nerve complications); (c) allergic reactions (often a mistaken diagnosis); and (d) mechanical or other effects of technique, such as needle trauma or introduction of infection. Signs and symptoms of CNS toxicity include convulsions, followed by coma and respiratory depression. Convulsions are due to disinhibition of nervous conduction, probably by an action at the gamma-aminobutyric acid (GABA) receptor complex, while depressant effects, which predominate at higher doses, are due to blockade of sodium channels. CNS toxicity is potentiated by hypoxia and hypercapnia, so acute management must minimise these. Cardiovascular toxicity also involves sodium channel blockade, reducing contractility and interfering with conduction. Bupivacaine differs from lidocaine (lignocaine) in the sudden occurrence of dangerous ventricular arrhythmias including fibrillation at subconvulsant doses. Ropivacaine is a newer amide local anaesthetic with toxicity intermediate between these but potency similar to bupivacaine. Neurotoxic complications leading to prolonged deficit after intraspinal administration are uncommon. Causes are multifactorial, and include pH of and additives to preparations. Allergic reactions account for only 1% of untoward reactions, but anaphylactoid collapse can be lifeth-reatening and requires rapid and effective management.


Dextromethorphan. An overview of safety issues. Dextromethorphan is a highly effective and widely used nonopioid antitussive drug. As it has been in use for more than 30 years, a large body of clinical experience has been used to formulate a safety profile. An anthology of adverse drug events has been analysed, drawn both from published case records and a data base recording dextromethorphan-related adverse events spontaneously reported by physicians or pharmacists. The resulting safety profile indicates that adverse drug reactions are infrequent and usually not severe. The predominant symptoms are usually dose related and include neurological, cardiovascular and gastrointestinal disturbances. Particular safety concerns arise when monoamine oxidase inhibiting (MAOI) drugs and dextromethorphan are coadministered. In addition to adverse drug reactions, the safety profile of dextromethorphan is affected by episodic and sporadic abuse. In fact, abuse appeared to be the most significant hazard identified by analysis of spontaneous adverse event reporting. No evidence could be found that the well documented pharmacokinetic polymorphism observed with dextromethorphan is correlated with any clinically significant safety risk if it is used for short term treatment. In summary, the safety profile of dextromethorphan is reassuring, particularly relating to overdose in adults and children.


On the possible mechanisms and predictability of clozapine-induced agranulocytosis. Studies were conducted on serum removed from 15 patients before, during, and after, clozapine-induced agranulocytosis. Cytotoxic studies were compared with samples taken from patients during treatment with clozapine who did not develop agranulocytosis or treatment controls (TC); additional controls consisted of allogeneic (NC) and autogeneic serum from apparently normal people. The effect of serum on measurable functions of polymorphonuclear neutrophils (PMNs) taken from normal people was tested. Procedures under study included suppression of post-phagocytosis-induced 14CO2-indicated respiratory burst, as well as ejection of trypan blue by test PMNs. PMNs exposed to active agranulocytosis serum plus complement displayed diminished 14CO2 emission during phagocytosis or failed to eject trypan blue. PMNs exposed to serum of TC and NC continued to function normally as regards 14CO2 emission and trypan blue ejection. Five patients studied before the development of agranulocytosis showed suppressed PMN function, which increased to peak value during agranulocytosis and then disappeared within 40 days of recovery. Similar suppression of colony forming units of granulocytes and macrophages (CFU-GM) was found whenever agranulocytosis serum was included in the marrow culture. The cytotoxic material required complement for its full expression, was not dialysable, was neutralised by anti-IgM serum, and was absorbed by test PMNs. Furthermore, solutions of clozapine or 5 of its metabolites offered no similar suppression of PMN function in vitro after incubation in an aqueous medium or with normal serum. These observations favour development of an immunogenic clone in sensitive people during active treatment with clozapine, which eventually leads to precipitous depletion of PMNs and their precursors. The early appearance of this suppressive substance may offer an early warning for development of agranulocytosis.


Possible role of free radical formation in drug-induced agranulocytosis. The use of clozapine, a unique antipsychotic drug, has been restricted due to a 1 to 2% incidence of drug-induced agranulocytosis. Many other drugs, including paracetamol (acetaminophen), can cause agranulocytosis, although with a much lower incidence. Metabolic activation of these drugs by neutrophils or stem cells could be the molecular mechanism underlying this adverse effect. Drug oxidation by myeloperoxidase leads to free radical metabolite formation; these reactive free radicals can oxidise glutathione to a thiyl free radical, which in the presence of oxygen forms oxygen-derived free radicals. In contrast to glutathione, when these free radical metabolites oxidise ascorbate an unreactive free radical is formed, which does not even react with oxygen. In both reactions, the free radical metabolite is reduced to the original drug, although ascorbate is the more effective reducing agent. Thus ascorbate, when coadministered with agranulocytosis-causing drugs, may inhibit free radical chain reactions and other free radical-mediated reactions, such as protein adduct formation, and thereby prevent drug-induced agranulocytosis.


Metabolism of clozapine by neutrophils. Possible implications for clozapine-induced agranulocytosis. Many types of adverse drug reactions appear to involve reactive metabolites which, by their very nature, usually have short biological half-lives. Therefore, reactive metabolites formed by neutrophils, or neutrophil precursors in the bone marrow, would seem more likely to be responsible for drug-induced agranulocytosis than metabolites formed in the liver. We have found that several drugs associated with a relatively high incidence of drug-induced agranulocytosis are metabolised by activated neutrophils to chemically reactive metabolites. In preliminary experiments with clozapine, we found that clozapine was metabolised by neutrophils. It also reacted with hypochlorous acid, the principal oxidant generated by neutrophils, to form a reactive intermediate. This intermediate has a half-life of 1 minute in buffer, but reacts very rapidly with glutathione. We believe that this intermediate is a nitrenium ion. Such a metabolite could be responsible for clozapine-induced agranulocytosis, either by direct toxicity or through an immune-mediated mechanism.


Major histocompatibility complex associations with clozapine-induced agranulocytosis. The USA experience. In order to determine associations between the major histocompatibility complex (MHC) and the development of clozapine-induced agranulocytosis, HLA typing was performed in a group of 42 clozapine-treated patients, of whom 11 had developed this adverse reaction. Among the patients with agranulocytosis, 7 (63%) were of Ashkenazi Jewish background and 4 (37%) were non-Jewish. An association between the HLA-B38, -DR4, -DQw3 haplotype and clozapine-induced agranulocytosis was found in all Jewish cases (7/7; 100%); in contrast only 4 of 21 (19%) Jewish control (nonagranulocytic) patients carried this haplotype. Among non-Jewish patients the HLA-DR2, -DQw1 haplotype was present in 4 of 4 (100%) patients with clozapine-induced agranulocytosis and in only 3 of 10 (30%) ethnically matched control patients. Our results indicate that gene products within the MHC could be involved in clozapine-mediated haematological toxicity.


HIV-1 western blot: development and assessment of testing to resolve indeterminate reactivity. To reduce the number of HIV-1 Western blot (WB)-indeterminates requiring follow-up and the time taken to provide a clear positive or negative result. In the first of two stages, a testing and follow-up strategy was developed to resolve anti-HIV-1 status of WB-indeterminates. In the second stage, implementation of this strategy was assessed. After dividing indeterminates into four groups according to WB profile, samples were tested for anti-HIV-1, anti-HIV-2, anti-HTLV-I antibodies, and HIV-1 antigen using the most sensitive assays available. When testing failed to clarify anti-HIV-1 status, follow-up samples were taken to monitor changes in antibody status. Samples in two out of the four indeterminate groups were negative for anti-HIV-1. The other two groups required additional testing and/or follow-up to distinguish reactivity caused by anti-HIV-1 from cross-reactivity. Grouping HIV-1 WB-indeterminates according to profile allows a significant percentage to be reported as anti-HIV-1-negative, while additional testing may allow others to be reported as anti-HIV-1-positive. The remainder require a maximum of 3 months' follow-up to resolve anti-HIV-1 status.


HIV-1 viral DNA load in peripheral blood mononuclear cells from seroconverters and long-term infected individuals. To determine viral DNA load in peripheral blood mononuclear cells (PBMC) from HIV-1-infected individuals. HIV-1 copy numbers were determined using a quantitative polymerase chain reaction (PCR), the PCR-aided template titration assay (PATTY). PATTY utilizes an internal plasmid control DNA, which is amplified within the same tube and using the same primers as the PBMC target DNA. HIV-1 copy numbers were confirmed by limiting-dilution PCR analysis. PBMC viral load of 19 long-term (greater than 4 years) HIV-1-infected individuals ranged from 0.8 to 100 copies per 10(3) PBMC. Significantly higher copy numbers were found among p24-antigen-positive than among p24-antigen-negative individuals. In addition, the PBMC viral load of two HIV-1-infected individuals was monitored during the first 3 months after acute infection. For both patients, the HIV-1 copy numbers were shown to peak at the time of HIV-1-antibody seroconversion and decline subsequently (range, 0.6-10 copies per 10(3) PBMC). PATTY is a useful method for assessing the HIV-1 copy numbers in PBMC DNA. Viral DNA load peaks shortly after infection and reaches an individual specific level that is probably stable within a few months of infection. Viral DNA load in PBMC varies widely among long-term HIV-1-infected individuals.


Relationship between cell-free viraemia, antigenaemia and antibody levels in HIV-1-infected Ethiopian patients. To determine the relationship and occurrence of cell-free viraemia, free or immune-complexed p24-antigen and p24-antibody levels in blood from HIV-1-infected patients in Ethiopia. Peripheral blood was obtained from 66 Ethiopian and 137 Swedish HIV-1-seropositive patients. Blood samples were analysed for free or immune-complex bound p24 antigen by enzyme-linked immunosorbent assay before and after acid hydrolysis of immune complexes for infectious virus in plasma and peripheral blood mononuclear cells (PBMC), and for p24-antibody levels. We compared the kinetics of viral replication of Ethiopian with Swedish isolates in vitro. Infectious virus was isolated from PBMC in 95% and from plasma in 81% of Ethiopian AIDS patients. In contrast, p24 antigen was detected in only 5% of AIDS patients from Ethiopia, compared with 76% of those from Sweden. p24-antibody levels were much higher and more persistent in Ethiopian than in Swedish subjects. The ratio between reverse transcriptase activity and p24 antigen was significantly higher in Ethiopian isolate culture than in those of the Swedish isolates. Our results show that relationships between viraemia, p24 antigenaemia and p24-antibody levels in HIV-1-infected Ethiopian patients differ from those found in comparable Swedish patients. This pattern may partly explain the differences seen in the natural course of HIV-1 infection in Ethiopia and Sweden.


Multicentre quality control of polymerase chain reaction for detection of HIV DNA. Seven French laboratories tested the specificity and sensitivity of the polymerase chain reaction (PCR) for the detection of HIV-1 DNA. Following its own PCR protocols, each laboratory independently tested blind two panels of 20 coded peripheral blood mononuclear cell samples collected from HIV-1-seropositive individuals and from HIV-1-seronegative individuals at high or low risk of HIV infection. For the first panel, laboratories were free to select type and number of primers; for the second, all were required to use the two primer pairs Pol 3/4 and MMy 9/10' (Nef 1). False-positive and false-negative results were observed in all laboratories (concordance with serology ranged from 40 to 100%). In addition, the number of positive PCR results did not differ significantly between high- and low-risk seronegatives. The use of crude cell lysates in DNA preparation produced the same PCR results as phenol-extracted DNA. Discrepancies between laboratories indicated that factors other than primer pairs contributed strongly to laboratory variability. Our results emphasize the importance of both positive and negative controls in PCR and demonstrate the value of multicentre PCR quality control.


Natural history of advanced HIV disease in patients treated with zidovudine. The Zidovudine Epidemiology Study Group. To describe the natural history of advanced HIV disease in patients treated with zidovudine. Longitudinal, observational study. Twelve academic and community-based sites. Eight hundred and sixty-three patients with AIDS or AIDS-related complex (ARC) with a CD4+ lymphocyte count less than 250 x 10(6)/l, who first received zidovudine between 15 April 1987 and 14 April 1988. Survival, progression to AIDS and first development of specific opportunistic illness. Median survival after initiation of zidovudine therapy ranged from greater than 900 days in patients with a baseline CD4+ lymphocyte count greater than or equal to 150 x 10(6)/l to 560 days in patients with a CD4+ lymphocyte count less than 50 x 10(6)/1. Other factors associated significantly with poorer survival were diagnosis of AIDS (versus ARC), baseline age greater than or equal to 40 years, hematocrit less than 35%, and diminished functional status. In patients with ARC at enrollment, median time of progression to AIDS ranged from 810 days in patients with a CD4+ lymphocyte count greater than or equal to 150 x 10(6)/l to 310 days in patients with a CD4+ lymphocyte count less than 50 x 10(6)/l. Rates of development of specific opportunistic infections or neoplasms and HIV encephalopathy were determined for different baseline CD4+ lymphocyte count ranges. Myelosuppression was significantly more common in patients with CD4+ lymphocyte counts greater than or equal to 100 x 10(6)/l. Sixty-five per cent of patients with a CD4+ lymphocyte count greater than or equal to 100 x 10(6)/l and 51% with a CD4+ lymphocyte count less than 100 x 10(6)/l continued to receive zidovudine 2 years after starting therapy. We describe the natural history of a cohort of patients treated with zidovudine for advanced HIV disease. These CD4+ lymphocyte count-stratified estimates of disease progression should provide prognostic information useful in the clinical management of advanced disease and the design of future studies.


Parvovirus infection in children with AIDS: high prevalence of B19-specific immunoglobulin M and G antibodies. Investigation of the prevalence and pathogenic role of parvovirus B19 infection in Italian and Rumanian children with AIDS, compared with age-matched HIV-negative children (controls) with various recurrent infections of unknown aetiology. Detection of B19-specific immunoglobulin (Ig) M and IgG antibodies as the most indicative markers of past or current B19 infection. B19 antibodies were detected by two enzyme immunoassays using synthetic peptide or recombinant protein, which corresponded to different B19 epitopes, as coating antigens. B19 IgM and IgG were seen in 10 out of 20 (50%) Italian and in 20 out of 51 (39.2%) Rumanian children with AIDS, in contrast to none out of 17 Italian and one out of 22 Rumanian controls (P less than 0.001). In addition, two Italian controls (11.8%), two Rumanian children with AIDS (3.9%), and two Rumanian controls (9.1%) had B19 IgM alone. Specific IgG alone was detected in eight (40%) Italian and 14 (27.5%) Rumanian children with AIDS, and in seven (41.2%) Italian and four (10.2%) Rumanian controls. While it is possible to attribute some B19 infections in Rumanian children to blood transfusion, the source was unknown for Italian children. However, in three of the Italian children who had B19 IgM and IgG persistently for 15-22 months, and in a 2-month-old Italian infant with B19 IgM and IgG, HIV might have activated a congenital or perinatally-acquired B19 infection.


Changes in neuropsychological performance of AIDS-related complex patients who progress to AIDS. To investigate the changes in neuropsychological performance associated with progression from AIDS-related complex (ARC) to AIDS. A repeated measures design was used to compare three groups: ARC patients who progressed to AIDS (n = 15), those who did not (n = 19) and seronegative controls (n = 16). The three groups were compared on tests of memory, information processing, motor performance, attention and conceptual flexibility. Clinical and immunological characteristics were recorded. Rates of neuropsychological impairment among the three groups were calculated and compared. The only significant difference between the groups at baseline was for one measure of motor performance. Repeated measures analysis indicated that there was a differential rate of change for the three subject groups for tasks of motor performance and attention. ARC patients who progressed to AIDS did not differ significantly from the non-progressors, although both groups showed significant deterioration over time compared with seronegative controls. Although there was a tendency for the progressors to have a higher rate of impairment, there were no consistent significant differences between visits. There were no significant changes in performance exclusively associated with progression to AIDS.


Specific nutrient abnormalities in asymptomatic HIV-1 infection. To determine whether specific nutrient abnormalities occur in earlier stages of HIV-1 infection, thereby preceding the marked wasting and malnutrition that accompany later stages of the infection. A longitudinal investigation to determine biological, psychological and social factors thought to influence the progression and outcome of HIV-1 infection. Nutritional status was assessed using biochemical measurement of nutrient levels, dietary history, anthropometry and clinical examination for the signs and symptoms of nutritional deficiency or excess. The study was performed on an outpatient basis at the University of Miami School of Medicine. One hundred homosexual men, aged between 20 and 55 years, who were asymptomatic other than persistent generalized lymphadenopathy (Centers for Disease Control stage III) and 42 age-matched homosexual men demonstrated to be free of HIV-1 infection at two 6-month intervals. Biochemical measurement of nutrient status, dietary history, anthropometry, clinical signs or symptoms of nutritional excess or deficiency were obtained for all participants. Despite few differences in mean blood levels of specific nutrients, prevalence of specific nutrient abnormalities was widespread among HIV-1-infected subjects, compared with non-infected male homosexual controls. Overtly and marginally low blood levels of vitamins A (18%), E (27%), riboflavin (26%), B6 (53%), and B12 (23%), together with copper (74%) and zinc (50%) were documented in HIV-1-seropositive subjects. With the exception of riboflavin, zinc, and copper, a similar prevalence of abnormalities among HIV-1-seronegative controls was not observed. Specific nutrient abnormalities occur with relative frequency in asymptomatic HIV-1 infection and may contribute to the rate and form of HIV-1 disease progression.


Experience with a totally implantable venous access device (Port-A-Cath) in patients with AIDS. To determine the complication rate of a totally implantable central venous access device [Port-A-Cath (PAC)] in AIDS patients, used mainly for home infusion therapy. A retrospective study. The study was performed at the AIDS Unit of the Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands. Forty-seven consecutive AIDS patients who had a PAC device implanted to receive either drug maintenance therapy (42 patients) or total parenteral nutrition (TPN; five patients). Fifty-one devices were implanted between June 1987 and October 1990. Mean puncture frequency was five times per week. The total number of catheter days was 9069. The total complication rate was 0.43 per 100 catheter days. Complications occurred in 17 (36%) patients: three implantation-related bleedings (0.03 per 100 catheter days), three puncture-related bleedings (0.03 per 100), two infections (0.17 per 100), seven occlusions (0.08 per 100), four flow problems (0.04 per 100) and one central vein thrombosis (0.011 per 100). Imminent skin necrosis at puncture site occurred in one case (0.01 per 100) and drug extravasation in two cases (0.02 per 100). Eight devices (17%) had to be removed. Primary septicaemias were resolved using antibiotics in three out of six patients in whom they occurred. Occlusions were almost exclusively caused by TPN. A totally implantable venous access device appears to be safe and convenient in (home) infusion therapy in AIDS patients, without risk of additional infection.


Anonymous HIV surveillance in Saughton Prison, Edinburgh. To estimate the prevalence of HIV by anonymous saliva testing in Her Majesty's Prison, Saughton (Saughton Prison), Edinburgh, UK. To elicit linked anonymous risk factor information from which to estimate risk scores for those who had taken an HIV blood test and, among drug injectors, for those who were HIV-1-antibody-positive on saliva testing. Saughton Prison on 15 and 16 August 1991; HIV Immunology and Regional Virus Laboratories, Edinburgh, and the Medical Research Council Biostatistics Unit, Cambridge, UK. Male inmates (378 out of a total of 499) of Saughton Prison. Answers to a brief questionnaire about age, usual residence, present and past custodial sentences, drug injecting and sexual behaviour prior to and in prison, HIV testing and history of acute hepatitis. HIV-1-antibody status was established by saliva testing. Eighteen per cent of participants were injecting drug users (IDU), of whom approximately one-half (47%) had injected while inside prison. Ninety men (26%), including 40 (14%) of 278 participants who had never injected drugs and 77% of IDU participants, had taken an HIV blood test. Nine per cent of all participants and 35% of IDU participants had had an acute attack of hepatitis. Forty-one (62%) of 66 IDU had been imprisoned five or more times before their current prison sentence. After taking account of region of residence, injecting drug history and acute hepatitis, aspects of sentencing and sexual behaviour were not determinants of those who had been tested for HIV. On the study days, 18 out of 499 (3.6%) participants were known to prison medical officers to be HIV-infected. Following saliva testing, HIV prevalence was 17 out of 375 (4.5%) inmates tested. All 17 had at some time 'taken the blood test for HIV' and all had injected non-medically prescribed drugs. Edinburgh residence, age 26-30 years, have injected in prison and having first injected before 1983 all contributed to the risk score for whether an IDU was HIV-1-antibody-positive on saliva testing. Documented HIV prevalence in saliva was 4.5%, which--assuming no volunteer bias (as supported by questionnaire returns)--suggests that actual HIV prevalence was 25% greater than revealed to Saughton's prison medical service. All 17 inmates who were HIV-1-antibody-positive on saliva testing had injected non-medically prescribed drugs. The high reported frequency by inmates of injecting in prison highlights the urgent requirement for drug reduction and rehabilitation programmes for injecting inmates. Linked anonymous voluntary HIV testing of saliva can provide valuable information about HIV prevalence for the planning of prison resources and policy.


[A drug evaluation and classification program in the USA--also a model for Germany]. The question of recognition and possibilities of proof regarding impairment by narcotics and drugs is gaining significance also in Germany. Therefore, it is necessary to deal more closely with the United States "Drug Evaluation and Classification Program" and consider its application in Germany as well. The American program is based on standardized education of drug recognition expert trainees and well-tested methods of examination. The results are convincing. The expert reports prepared by the examiners and the chemical-toxicological results correlate in 80 to 97% of the cases. As long as no definite findings regarding dose/concentration effect relationships exist, the classification of behavior, appearance and medical examination plays a significant role. To a great extent, the program makes allowance for the existing possibilities in Germany as well. The authors of this article would consider it to be wrong if, in Germany extensive, time-consuming field studies were undertaken to obtain further knowledge prior to introduction of such a program. On the other hand, despite the existing difficulties, it should be endeavored to find dose/concentration effects.


[Effect of alcohol as a cause of fatal traffic accidents: are official figures correct?]. Starting point is the question whether in the official records of fatal road accidents driving while intoxicated is adequately taken into account as a cause. A former investigation with accident data of 1976 yielded a considerable number of undetected and not registered cases. On the basis of the fatal road accidents of the Saarland region for the years 1988, 1989 and 1990 the former results could be confirmed on the whole. Only with 25 per cent of all persons involved in a fatal accident a breath or blood test for checking alcoholic impairment had been arranged. The assumption is well substantiated that the remaining 75 per cent include many impaired persons and that not only every fifth victim of traffic accidents is a result of alcoholic impairment but about 40 per cent. Proposals are made for getting in the future more reliable counts and a better basis for fighting against DWI-offences.


[Leaving the scene of an accident--a special offense in forensic psychiatric assessment?]. A retrospective study on a hit-and-run group of drivers is reported. In comparison with a control group the study did not reveal special characteristics of these offenders. Mechanisms responsible for a driver leaving the place of a traffic accident are discussed. With reference to driver's escape psychogenic reactions and alcoholic intoxication often are observed, while (post-traumatic) twilight states and brief reactive psychosis are extremely rare events. Intensity of psychological disturbance during the offence may be assessed by criteria for evaluating responsibility of offenders with crimes of passion.


[Long-term rehabilitation of alcohol dependent drivers (1)--individual psychologic traffic therapy]. The "Individualpsychologische Verkehrstherapie (IVT-Hö)" is a rehabilitation measure for accident-prone drivers. In it are treated principally drivers who are problem drinkers, for whom the usual re-education is unsuitable because of severe alcohol problems. IVT comprises a psycho-therapeutic process, medical care and traffic re-education, and is tailored to individual problem situations respectively. A scientific study of the success rate indicates that through IVT, reductions of the probability of relapse are achievable, which far exceed even the effectiveness of re-education carried out with fewer problematical cases (e. g. Leer model).


Management of the paralyzed face with microneurovascular free muscle transfer. Facial paralysis is a devastating physical condition in which no single therapeutic approach consistently restores mimetic facial expression. The purpose of this article is to review the current treatment modalities for facial paralysis with particular emphasis on the indications for using free flaps to achieve facial reanimation. Primary attention is given toward rehabilitation of the lower two thirds of the face. The various neuromuscular free flaps used for facial reanimation are described and their merits and deficiencies are discussed.


Complications and early outcome of anterior craniofacial resection. To evaluate the complications of anterior craniofacial resection and correlate their impact with tumor control status. We conducted a retrospective review of 32 consecutive, operable patients' records seen over a 6-year period, requiring 35 procedures. Academic tertiary referral medical center. Twenty-six patients (81%) had malignant lesions (esthesioneuroblastoma, squamous cell carcinoma, and a group of miscellaneous malignant tumors). Six patients had various benign neoplasms. The surgical approach involved bifrontal craniotomy coupled with lateral rhinotomy in 19 cases (61%), facial degloving in 10 cases (32%), a total rhinectomy in one case, and endoscopic sinusectomy without facial incision in two cases. Clinically noted complications and oncologic outcome. There was one avoidable perioperative death indirectly associated with the patient's procedure. Nine patients suffered significant intracranial neurological complications such as tension pneumocephalus and delayed epidural abscess. All of these complications were managed successfully. Of patients with malignant tumors, 13 (52%) are alive with no evidence of disease and one is alive with recurrence after a mean follow-up period of 28.9 months. The 10 patients who succumbed to disease had a mean postoperative survival of 22.9 months. In contrast to the perspective of only a decade ago, we conclude that craniofacial resection is a relatively safe, versatile, and effective procedure for surgical management of tumors involving the anterior skull base.


Accuracy of pathologic diagnosis in thyroid lesions. Although there is much literature devoted to the role that fine-needle biopsy plays in the management of the thyroid mass, only a handful of studies deal with the diagnostic accuracy of the frozen section and final paraffin section of thyroid lesions. Fine-needle biopsy results, frozen-section diagnoses, final paraffin-section diagnoses, and panel review diagnoses were recorded for 137 consecutive patients who underwent thyroidectomy procedures. The overall accuracy of fine-needle biopsy, frozen-section, and paraffin-section diagnoses was 81%, 87%, and 94%, respectively. The high positive predictive value and specificity of both the fine-needle and frozen-section modalities suggests that intraoperative pathology consultation, given that the preoperative needle aspirate is positive for malignant neoplasia, can offer little further in the treatment of the patient. Statistical analysis of the accuracy of the three modalities suggests strategies for accurate treatment of the thyroid nodule.


Pathological basis of surgery in the management of postradiotherapy cervical metastasis in nasopharyngeal carcinoma. Radical neck dissection was performed on 43 patients with nasopharyngeal carcinoma in whom persistent or recurrent cervical metastasis developed after radiotherapy. The pathologic nature of the tumor in the cervical lymph nodes was studied with step serial sectioning of the entire radical neck dissection specimen at 3-mm intervals. In 70% of patients, more tumor-harboring lymph nodes were detected in the specimen when compared with clinical examination. The extensive behavior of the tumor in the cervical metastases was reflected by the presence of extracapsular spread in 70% of the lymph nodes and the existence of isolated clusters of tumor cells in 35% of the specimens studied. Tumor tissue lying in close proximity to the spinal accessory nerve was demonstrated in 27.5% of the specimens, and 72% of the tumor-bearing lymph nodes were located in the posterior triangle. Radical neck dissection is recommended as the salvage procedure for these patients.


Experience with the modified pectoralis major myocutaneous flap. Results of 75 reconstructions with a modified pectoralis major myocutaneous flap are described in patients with advanced (stages III and IV) head and neck tumors between 1982 and 1986. The course of the supplying thoracoacromial artery was determined with angiographic studies and was found to follow the middle clavicular line in most cases. The pectoralis major muscle was mobilized up to its acromial attachment, which made the bridging of considerable distances possible between the site of the removed tumor and the donor site. The bulk of the pedicle was reduced at the same time without endangering the safety of the blood supply of the pectoralis major myocutaneous flap. The flaps were viable in the 70 evaluable patients. Partial necroses were observed in three cases. Postoperative fistulas were encountered in 13 patients (surgical closure was necessary in three). Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.


Paranasal sinusitis associated with nasotracheal and orotracheal long-term intubation. The impact of nasotracheal and orotracheal long-term intubation on the development of sinusitis paranasalis was investigated in a prospective study. Daily A-scan ultrasound examinations of the maxillary sinuses were performed on 44 intensive care unit patients (20 nasally, 24 orally intubated) who required prolonged intubation (greater than 24 hours). At the end of the investigation period 19 (95%) of 20 nasotracheally and 15 (63%) of 24 orotracheally intubated patients showed pathologic antral sinus findings. In nasally intubated patients the incidence of bilateral sinusitis was significantly higher and its onset sooner. Pathologic organisms were found in the sinus aspirates in seven of 13 nasotracheally intubated patients, but only in two of nine patients with an oral tube. Thus, the nasotracheal tube can be seen as an adding factor in the development of sinusitis paranasalis.


Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. A retrospective study of pediatric patients with obstructive sleep apnea who underwent adenotonsillectomy between 1987 and 1990 was undertaken to determine the frequency of postoperative respiratory compromise and to determine if risk factors for its development could be identified. Sixty-nine patients less than 18 years old had polysomnographically documented obstructive sleep apnea and were observed postoperatively in the pediatric intensive care unit. Of these, 16 (23%) had severe respiratory compromise, defined as intermittent or continuous oxygen saturation of 70% or less, and/or hypercapnia, requiring intervention. Compared with patients without respiratory compromise, these patients were younger (3.4 +/- 4 vs 6.1 +/- 4 years) and had more obstructive events per hour of sleep on the polysomnogram (49 +/- 41 vs 19 +/- 30). They were more likely to weight less than the fifth percentile for age (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.4 to 18.7), to have an abnormal electrocardiogram and/or echocardiogram (OR, 4.5; 95% CI, 1.3 to 15.1), and to have a craniofacial abnormality (OR, 6.2; 95% CI, 1.5 to 26). Multiple logistic regression analysis revealed the most significant risk factors were age below 3 years and an obstructive event index greater than 10. Children with obstructive sleep apnea are at risk for respiratory compromise following adenotonsillectomy; young age and severe sleep-related upper airway obstruction significantly increase this risk. We recommend in-hospital postoperative monitoring for children undergoing adenotonsillectomy for obstructive sleep apnea.


Histiocytosis X of the head and neck in a pediatric population. Despite an extensive literature, histiocytosis X is still a poorly understood disease and the origin remains unknown. To study the impact of recent therapeutic and diagnostic advances on this disease, 28 cases of histiocytosis X treated at Children's Hospital of Los Angeles, Calif, from 1976 through 1987 were reviewed. A classification system was developed that accurately described the clinical outcome in our patients. Type patients (n = 7) had monostotic disease, and type 2 patients (n = 15) had multiple tissue sites other than the viscera. The latter type was further divided into types 2A and 2B, depending on whether lesions were solely osseous (type 2A [n = 8]) or if soft-tissue sites were involved (type 2B [n = 7]). Type 3 patients (n = 6) had disseminated disease at the time of presentation, as defined by visceral involvement other than the liver. Type 1 patients were usually treated by surgical curettage alone and had an excellent prognosis. Type 2A patients required either surgery or radiation for symptomatic lesions. Type 2B patients were treated similarly. In addition, Type 2B patients received chemotherapy, a practice that is intensively debated in the literature. All the Type 2 patients survived with varying morbidity. Type 3 patients were all treated with chemotherapy but none of them survived. The majority of patients with histiocytosis X had otolaryngologic manifestations ranging from bony lesions to infectious complications. To conclude, the term histiocytosis X should be maintained to describe a spectrum of diseases. A simple classification system with three divisions gives reliable prognostic and therapeutic guidelines.


Side effects of repeated ototopical application of fosfomycin. An animal study. In view of the possible role of fosfomycin in the topical treatment of chronic suppurative otitis media, the effects of this drug on inner ear function were investigated. Fosfomycin (20% aqueous solution) was applied repeatedly to the round window membrane of both ears of pigmented guinea pigs. Hearing thresholds were determined by daily frequency-specific evoked response audiometry with stimulation frequencies ranging from 1 to 32 kHz. Both positive (neomycin) and negative (saline) controls were included. Results were analyzed statistically. No significant and progressive hearing loss was found with fosfomycin. At 32 kHz, however, the hearing levels at the end of the test period were significantly worse in the fosfomycin group than in the saline group.


Eyelid level after lower lid blepharoplasty with skin excision. The relationship of intraoperative and postoperative lid levels. Sixty-seven consecutive patients (134 lids) undergoing lower lid blepharoplasty with skin excision had preoperative, intraoperative, and postoperative photographs taken in a sitting position. There was correlation between intraoperative and postoperative lower lid levels in 119 (89%) of 134 lids. There were nine lids with normal intraoperative lower lid level but postoperative lower lid retraction (scleral show). All nine of these lids had preoperative lower lid retraction. This demonstrated a high correlation between intraoperative and postoperative lower lid levels in the sitting position in lower lid blepharoplasty with skin excision, providing preoperative lower lid retraction is not present, horizontal lid laxity is corrected, and cicatricial lid retraction does not occur.


Rigid endoscopy for the control of epistaxis. Six individuals were selected to undergo rigid nasal endoscopy and electrocautery for treatment of refractory epistaxis. This intervention was successful in five cases, with no major complications. The procedure was found to be both cost-effective and acceptable to the patient population.


The first branchial cleft carcinoma.

The first branchial cleft carcinoma. Primary branchiogenic carcinoma was previously a debated entity. Initially it was a popular diagnosis for many cystic carcinomas of the neck. Then, in 1950, stringent criteria were defined for establishing the diagnosis of primary branchiogenic carcinoma. Only a limited number of cases have successfully fulfilled these criteria. We describe a patient who meets the criteria and who we believe represents the first reported case of a carcinoma arising from the vestigium of the first branchial cleft. We also review the literature on branchial cleft carcinomas and discuss the diagnosis, histopathologic features, and therapeutic options.


Cholesteatoma of the maxillary sinus.

Cholesteatoma of the maxillary sinus. Cholesteatoma of the maxillary sinus, also known as keratoma, primary epidermoid tumor, epidermoid cyst, and keratocyst, is a rare entity, with a clinical presentation and radiologic findings that are difficult to distinguish from those of malignancy. We report a case of cholesteatoma of the maxillary antrum that occurred in a 12-year-old boy without any history of predisposing factors. Multiple theories of pathogenesis have been proposed throughout history; currently there are two accepted ones. We discuss these theories and present, along with the differential diagnosis, a review of the literature and the characteristic radiologic and pathologic findings. While it is a rare entity, the diagnosis of cholesteatoma should be considered for any slowly expanding lesion of the maxillary antrum.


Bilobed flap reconstruction of the temporal forehead. The temporal forehead is a particularly challenging area for reconstruction. Temporal forehead skin lies in a broad flat plane that varies in thickness. The eyebrow, scalp hairline, and lateral canthus comprise its aesthetic boundaries and limit the available tissue for repair of defects. Characteristically, skin tumors of the temporal forehead have extensive subclinical spread and their removal leaves large defects. The goal of temporal forehead reconstruction is to recreate the aesthetic boundaries of the forehead and to regain symmetry with the contralateral side. The temporal forehead bilobed flap is a single-stage procedure that takes advantage of the best color match of adjacent tissue and often allows primary closure of the donor sites in relaxed skin tension lines with minimal distortion. Several cases are presented for illustration of the technique.


Preoperative thyroid scanning in presumed thyroglossal duct cysts. The purpose of this study was to determine if preoperative thyroid scans are essential in the workup of presumed thyroglossal duct cysts. Questionnaires were sent to pediatric otolaryngologists and pediatric general surgeons with a 65% response rate. Fifty-seven percent of the physicians have encountered ectopic thyroid. In 58% of these, this was the only functioning thyroid tissue. Twenty eight percent of pediatric surgeons vs 65% of pediatric otolaryngologists routinely order scans. Two of the physicians encountering ectopic thyroid volunteered that they had successful litigation directed against them for removing the sole functioning thyroid and creating permanent hypothyroidism. There is a likelihood of encountering ectopic thyroid during the course of one's practice. A case of ectopic thyroid is presented, and management strategies are discussed.


Congenital nasal pyriform aperture stenosis. Isolated abnormality vs developmental field defect. Congenital nasal pyriform aperture stenosis has recently been described as a cause of nasal airway obstruction in the newborn. As some investigators have observed, the nasal pyriform aperture is narrowed owing to bony overgrowth of the nasal process of the maxilla. This overgrowth is confirmed by computed tomography. In six previously reported cases, follow-up as long as 16 months revealed normal facial growth. We describe six patients with congenital nasal pyriform aperture stenosis. On eruption of deciduous dentition, four of the six patients were found to have a single prominent central maxillary incisor, ie, "megaincisor." Computed tomographic scans have confirmed this dental anomaly as well as maxillary bony overgrowth. A single maxillary incisor has been described as an autosomal dominant microform of holoprosencephaly, a developmental field defect. We propose that in some patients congenital nasal pyriform aperture stenosis may represent more than an isolated congenital abnormality of the airway and may, in fact, be a midfacial dysostosis with associated endocrine and central nervous system abnormalities.


Hereditary hemorrhagic telangiectasia. A new dermoplasty technique. A new dermoplasty technique is described that allows both sides of the nasal septum to be covered with a single split-skin graft. This graft is designed with a narrow central dermal band that covers the septal dorsum and can be buried under the alar tissues. Exposure is obtained via a modified external rhinoplasty approach. The operation has been successfully performed on 11 patients, and in nine of them the graft take was complete.


Paraganglioma of the inferior laryngeal paraganglia. A case report. Laryngeal paragangliomas are uncommon, usually benign neoplasms. The overwhelming majority of these tumors are supraglottic, arising from the superior laryngeal parasympathetic paraganglia. Few paragangliomas of the infraglottic region have been described. We describe the case of a 35-year-old man with a family history of carotid body tumors who presented with an infraglottic paraganglioma.


Cytoplasmic and nuclear volume in the neurons of the spinal ganglia of the lizard: observation during hypertrophy. It is known that neurons can undergo a process of hypertrophy when they are involved in an increase of the innervation field. This situation is easily observable in the spinal ganglia of the lizard which innervate the regenerated tail. Morphometric analysis carried out on the whole neuronal population of such ganglia has shown a greater increase of cytoplasmic volume with regard to the nuclear volume during hypertrophy (a decrease of the nucleo-plasmic index). Hypertrophy in the neurons of lizard spinal ganglia has been analysed both in still growing animals and in adults after amputation of the tail, showing analogous behaviour in the two situations. This suggests that the physiological growth of the animal does not influence the reaction to hypertrophy.


[Satellite cells of te dorsal root ganglia in neuronal hypertrophy]. Amputation of the lizard tail is followed by its complete regeneration over a period of six-eight months. The new tail is innervated only by the last three pairs of spinal nerves upstream from the plane of amputation, since no nerve cells are present in the regenerated. The corresponding dorsal root ganglia increase in volume (hypertrophic ganglia) and most of their sensory neurons become hypertrophic. Satellite cells belonging to this hypertrophic ganglia increase in number. This paper describes an autoradiographic study, after administration of tritiated thymidine, of the hypertrophic dorsal root ganglia of the lizard during tail regeneration. We evaluated the number of satellite cells which neo-synthetize DNA ("labeling index = LI%) and are therefore suitable to undergo cell division. The LI% was significatively increased in hypertrophic ganglia when compared to internal control ganglia (not directly involved in the reinnervation process) and normal ganglia (lizards with intact tails). The comparison between internal control ganglia and normal ganglia showed higher LI% values in the formers, although this difference was not statistically significative. These results are in line with those obtained by other authors and suggest that satellite cells of dorsal root ganglia can undergo cellular proliferation also in the adult, especially in particular experimental conditions.


[Presence of calretinin in neurons of the human intestine]. Calcium-binding proteins are present in different neuron populations in the Central Nervous System. As concerns the Enteric Nervous System, only a few studies have been performed. In the present work we investigated immunohistochemically the localization of Calretinin in neurons of the human intestinal wall. Our results showed the presence of stained cell bodies and fibers with antibodies against Calretinin in the Auerbach plexus. Since most of the enteric neurons are characterized by a slow phase after hyperpolarization caused by Ca2+ dependent K+ channels, the role of Calretinin could be to modulate this particular electrophysiological behaviour.


Serum neuron-specific enolase in various pathological conditions. Quantitative determination of neuron-specific enolase in the serum was performed by RIA method in 18 neurological patients and in 22 patients with pulmonary diseases. The data confirmed that the specificity of this marker is not absolute for the detection both of the nature and of the seat of origin of the disease. Further problems are posed in patients which simultaneously suffer from endocrine, nervous and pulmonary abnormality.


Immunogenotypic characteristics of chronic lymphocytic leukemia patients from northern Italy. Ig gene analysis, carried out in 25 patients failed to show rearrangement patterns typical of each stage, but, nevertheless, confirmed the monoclonal origin of leukemic cells in these patients. In addition, in 14 of them the pattern of Ig gene rearrangements measured on two different occasions was analyzed. Only in patients who had received chemotherapy, the intensity of the Ig germline band was greater than that of the rearranged bands, indicating the reduction of lymphocytosis after the therapy. Thus, though Ig gene rearrangement could not distinguish the CLL stage, our data confirm the usefulness, at all clinical stages, of Ig gene analysis as a tool in the evaluation of the efficiency of the therapy.


A few remarks on the morphogenesis of the larynx. After having reviewed the principal theories regarding the development of the larynx the authors performed a study on the morphogenesis of the above structure using four horizontally- and sagitally-sectioned human embryos. The conclusion of a study of these sections is that the LC constitutes the primordium of the laryngeal vestibule. From its lateral margin, caudally (Stage 19, Carnegie System), the primitive ventricles begin to form, while in the final stages the EL extends caudally enclosing a small cephalic infraglottic area and therefore completely separating the IG from the LC. Such findings in our opinion would confirm a different embryological derivation of the laryngeal cavity above and below the glottis.


Effect of N-2-acetylaminofluorene on poly(ADP-ribose) polymerase activity and DNA synthesis in cultured rat hepatocytes exposed to epidermal growth factor. The nuclear enzyme poly(ADP-ribose) polymerase is involved in basic cellular processes such as DNA replication and repair, cell differentiation and transformation, gene expression. We have studied the effect of 2AAF, a genotoxic aromatic amine, on pADPRP activity during DNA synthesis stimulated by EGF, using the cultured rat hepatocytes model. DNA synthesis was measured as [3H]thymidine incorporated/microgram DNA while pADPRP activity was expressed in pmol[32P]NAD incorporated/min/microgram DNA. Our results show that 2AAF treatment of EGF-stimulated rat hepatocytes induces a full block of DNA replication which is preceded and accompanied by a net inhibition of endogenous and total pADPRP activity, respectively. A block in pADPRP activity in normal hepatocytes, exposed to 2AAF in vitro or in vivo, could play a key role in cell transformation. Our data add further information on the possible involvement of this nuclear catalytic activity during DNA replication.


The extracellular matrix in slow-growing tumors of the central nervous system. This report describes and illustrates the results of the histopathological and histochemical investigation on five slow-growing tumors of the central nervous system: four meningiomas and an ependymoma of the spinal cord. We have studied, by means of polarizing microscopy, sections stained with picro-sirius red F3BA that enhance the birefringence of collagen and reticulum fibres. The heterogeneous behaviour of the distribution of the collagen let us conclude that the fibrillar component of the extracellular matrix have a scarce importance for the speed of growth of these tumours.


[Recall of the proper names of persons: effect of age and the modality of access]. Aging is associated with phenomena of slowing down of cognitive processes and impairment of neuropsychological performances. Elderly people also report difficulty in the retrieval of proper names. Verbal fluency (VF) tests are particularly effective for the identification of even slight mental impairments. In this experiment we utilized the usual tests of VF for semantic categories and letters of the alphabet together with three new tests of VF for first names, differing in mode of access. The first mode was free recall, the second mode was semantic (first names beginning with a particular letter), and the third mode was autobiographical (first names of relatives). There were 3 experimental groups: young people with high education level, elderly people with high education level and elderly people with low education level. The aim of our work was to verify whether aging modifies the performance in the VF tests, particularly in the three first name VF tests. No difference was found between the groups of young and elderly people with high education level. The comparison between the two groups of elderly people, with high and low education level, showed that significant differences were present in some but not in all of the VF tests. While the two groups clearly differed in semantically oriented tests, no difference could be detected in the test oriented to episodic memory. This result seems to be inconsistent with the hypothesis that aging affects mainly episodic memory.


[Hyperplasia of the intestinal smooth muscle tissue proximal to a partial surgical stenosis: an autoradiographic study]. Hypertrophy of the smooth muscle wall of the rat small intestine occurs in the loops upstream from a partial surgical stenosis. This phenomenon is due both to cell hypertrophy and cell proliferation (hyperplasia). The thickness of the muscular layers reached its maximum after ten days from the intervention and then was maintained over the following days. Hyperplasia of the smooth muscle tissue has been demonstrated by means of autoradiography after administration of tritiated-thymidine. This investigation revealed the presence of 37%-44.5% of heavily labeled smooth muscle nuclei, index of active DNA neo-synthesis. On the contrary, no labeled nuclei were observed in the downstream tract as well as in the small intestine of the controls. These results, together with those obtained by other researchers, confirms that the smooth muscle tissue can undergo cell proliferation under particular conditions and that this phenomenon is often associated with the hypertrophic process.


Enhanced sensitivity to G418 of human KB cells adapted to certain media and sera. Sensitivity to the neomycin derivative G418 was determined for a human cell line, KB 3-1, that had been adapted to six different combinations of media and sera. The results indicate that while the plating efficiency is similar for all conditions, the susceptibility to G418 can differ markedly depending on the particular combination of media and sera used. This suggests that in experiments using neomycin resistance as a selectable marker, conditions may be found where the amount of G418 required for selection and maintenance of transfected cell lines can be reduced, providing a significant savings.


Using proteases to avoid false identification of DNA-protein complexes in gel shift assays. Gel mobility shift assays using crude nuclear extracts may result in the formation of multiple DNA-protein complexes reflected by their discrete gel mobilities. Identification of the multiple complexes can sometimes be complicated by the presence of protease activities in the extract as demonstrated here. We describe a simple protease-mediated partial digestion method that can be coupled with the gel shift assay to overcome the problem. The combined approach enables us to identify gel complexes that arise from protein degradation and therefore is suitable for analyzing those DNA-binding proteins exhibiting prominent protease sensitivity. The method should prove particularly informative in the search for tissue-specific complexes when crude extracts from different sources are compared by the gel shift assay.


Direct PCR of washed blood cells.

Direct PCR of washed blood cells. We report a simple and rapid method for direct DNA amplification of washed blood cells by PCR. Small samples (2-100 microliters) of blood were washed, the cells resuspended in a buffer and used directly for PCR after boiling. Amplification of a specific DNA sequence of the human transthyretin gene, directed by the primers, was successfully performed. The method gives comparable results to amplifications made by purified DNA from blood.


Recombinant circle PCR and recombination PCR for site-specific mutagenesis without PCR product purification. Two simple methods for site-specific mutagenesis are described and compared. In each method, the PCR is used in two separate amplifications to mutate the site of interest and to add ends to one PCR product that are homologous to the ends of the other PCR product. In the first method, the two products are combined, denatured and reannealed prior to transformation of E. coli in order to form recombinant circles in vitro, while in the second method, the two linear products are co-transfected directly into E. coli without prior manipulation, resulting in transformation of E. coli with the recombinant of interest by recombination in vivo. Each PCR amplification uses a plasmid template that has been linearized by restriction enzyme digestion outside the region to be amplified. This permits use of unpurified PCR products in these two protocols and generation of the mutant of interest with no other enzymatic manipulation in vitro apart from PCR amplification. In each protocol greater than or equal to 50% of the resulting clones contained the mutation of interest without detected errors.


Use of a ligand-screening procedure to study the interaction of S. cerevisiae alpha 2 repressor with its operator sequence. A simple and rapid screening procedure was developed to study the interaction of the S. cerevisiae alpha 2 repressor with its operator sequence. An E. coli expression vector was constructed in which the alpha 2 coding sequence was placed under control of the lac promoter. Bacterial colonies containing this vector could be lysed and assayed directly for binding of wild-type and mutant operator sequences when grown on nitrocellulose filters. alpha 2 assayed in this way showed the same sequence specificity as determined in vivo. Pools of mutant alpha 2 repressors in which the codons for Arg185 or Ser181 in the homeodomain region were randomized were created by cassette mutagenesis. These pools of mutants were screened with the wild-type operator sequence to determine allowed amino acid substitutions at each position. Results suggest that both Arg185 and Ser181 have a role in high affinity operator binding.


Recombinant peptides as immunogens: a comparison of protocols for antisera production using the pGEX system. Using an inducible vector system that directs high-level production and rapid purification of recombinant protein, we have immunized mice with peptides prepared by several methods: 1) samples fractionated by sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) subsequently transferred to PVDF membrane and subcutaneously implanted in mice; 2) samples cut directly from SDS-PAGE gels and injected intraperitoneally; 3) injection of recombinant protein bound to agarose beads; and 4) injection of log-phase E. coli transformed with recombinant vector. All four strategies yielded specific antisera reacting with both the parental fusion protein and the recombinant fragment as determined by enzyme-linked immunosorbent assay and immunoblot analysis. Specific recognition of the recombinant fragment was demonstrated by a competitive inhibition assay in which the parental fusion protein abrogated reactivity of serum with the isolated recombinant fragment.


Production of recombinant rat interleukin-6 in Escherichia coli using a novel highly efficient expression vector pGEX-3T. Interleukin-6 (IL-6) is one of the most important mediators of the acute phase reaction in liver. For the production of recombinant rat IL-6 in Escherichia coli, a previously isolated cDNA coding for the rat IL-6 was cloned into the modified novel expression vector pGEX-3T. The IL-6 cDNA was highly expressed as a fusion protein with the glutathione S-transferase (GST) at its C-terminus and rat IL-6 at its N-terminus. The GST-IL-6 fusion protein was controlled by a tac-promoter and could be induced very efficiently by isopropyl-beta-D-thiogalactopyranoside. The synthesized GST-IL-6 fusion protein was insoluble and precipitated intracellularly in E. coli. Using an advanced technique, the insoluble protein was solubilized and purified to homogeneity by affinity chromatography using immobilized glutathione in a one-step procedure.


Rapid separation of DNA molecules by agarose gel electrophoresis: use of a new agarose matrix and a survey of running buffer effects. This report describes the use of a new type of agarose (FastLane agarose) for faster separation of DNA by agarose gel electrophoresis. DNA molecules separated in this agarose exhibited electrophoretic mobilities up to 30% higher than similar separations in standard analytical grade agarose. DNA molecules of all sizes examined showed higher mobilities in FastLane agarose. The mobility increase was predominantly due to the low electroendosmosis of FastLane agarose and was most pronounced in pulsed field gel electrophoresis separations. The magnitude of mobility increase varied depending on the conditions used for electrophoresis.


A mechanically strong matrix for protein electrophoresis with enhanced silver staining properties. Duracryl is a mechanically strong and elastic acrylamide-based matrix, useful for a wide variety of electrophoretic applications. The matrix is stable as a refrigerated solution for one year. Upon addition of appropriate catalysts, Duracryl forms a polymer-reinforced polyacrylamide gel matrix suitable for electrophoresis. The polymer-reinforced gel is superior to conventional polyacrylamide gels in terms of mechanical strength, elasticity and protein silver staining properties. Protein detection sensitivity by silver staining, as well as the linear response of silver deposition versus protein load, is equivalent to standard acrylamide/N,N'-methylene bisacrylamide gels. Additionally, the silver staining properties of the Duracryl matrix result in proteins appearing as monochromatic shades of grey instead of red, brown and yellow, as is the case of conventional polyacrylamide matrices. Monochromatic shades of grey are more suitable for image analysis and densitometry. The matrix is compatible with standard electroblotting and protein N-terminal sequencing procedures. Low acrylic acid content and conductivity allow incorporation of the matrix into isoelectric focusing gels. The matrix was found not to alter polypeptide migration relative to the standard acrylamide/N,N'-methylene bisacrylamide matrix.


A simplified method for determination of specific DNA or RNA copy number using quantitative PCR and an automatic DNA sequencer. Quantification of specific RNA or DNA molecules that are present in minute amounts in biological samples has previously been performed using PCR in the presence of an internal standard. We have adapted this concept by introducing several modifications that facilitate the quantification of the products and obviate the need for radioisotopes. After amplification, individual products are separated on sequencing gels and directly quantified using a fluorescent automated DNA sequencer. We describe two applications of this approach: the quantitation of minute amounts of bcr-abl hybrid mRNA from malignant cells and the determination of gene copy number in cells stably transfected with a plasmid bearing a chloramphenicol acetyltransferase gene.


A two-step hybridization method for chemiluminescent detection of single copy genes. We have developed a technique for the chemiluminescent detection of single copy genes that eliminates the high backgrounds and problems with probe labeling associated with existing methods. The procedure employs a primary hybridization of single-stranded probe DNA to immobilized target DNA, a secondary hybridization with a covalently cross-linked oligonucleotide-alkaline phosphatase conjugate, followed by incubation in the chemiluminescent substrate AMPPD and detection on x-ray film. The key to the success of this method is that the primary probe contains a region complementary to the target DNA as well as to the oligonucleotide sequence of the secondary probe-alkaline phosphatase conjugate. Here we report our results using the two-step hybridization procedure to detect single copy genes from genomic Southern blots.


A new approach to template purification for sequencing applications using paramagnetic particles. A new method using traditional hybridization methodology, coupled with the new magnetic particle technology, has been developed for DNA purification, specifically for sequencing applications. The method is similar to the reverse hybridization blot system; however, a specific oligonucleotide probe was attached to the paramagnetic particle instead of a sheet membrane. The target DNA containing the complementary sequence of the probe hybridizes to the probe that is attached to the bead and is then magnetically removed from solution, washed and collected. This system eliminates the need of organic extractions and precipitation/concentration steps. The entire hybridization-purification system can be done in a 1.5-ml microcentrifuge tube making the method ideal for automation. M13 phage clones were purified with this method, both by manual means and by using the CATALYST 800 Molecular Biology LabStation fitted with a prototype magnetic station, and then sequenced. DNA sequencing results obtained with this system were reproducible and gave excellent length of read with low background.


Use of a novel agarose gel-digesting enzyme for easy and rapid purification of PCR-amplified DNA for sequencing. The use of a novel gel-digesting enzyme preparation provides an easy, rapid and convenient method to quantitatively recover PCR-amplified DNA from low melting point agarose gels. The PCR products purified using this method were readily sequenced and yielded good and unambiguous sequence data.


Automated sequencing and mapping of cosmid DNA with fluorescently-labeled dideoxynucleotide terminators. We have established a method for directly sequencing cosmid DNA on an automated DNA sequencer. The major advantage of this method is that only small amounts of cosmid template DNA are needed for the sequencing reactions.


Double-stranded dideoxy sequencing from "dirty" DNA--done in a day. A rapid method for preparing and directly sequencing plasmid and phagemid miniprep DNA is described. This protocol is a novel combination of two fairly standard procedures, resulting in quick and easy generation of sequence data. The lack of extensive manipulations in the purification process allows the production of DNA sequence data in a single day.


A quick and inexpensive method for removing polysaccharides from plant genomic DNA. A quick and inexpensive method has been demonstrated to remove polysaccharide contamination from plant DNA. Isolated plant genomic DNA with polysaccharide contaminants was dissolved in TE (10 mM Tris-HCl, pH 7.4, 1 mM EDTA) with NaCl ranging from 0.5-3.0 M, then precipitated with two volumes of ethanol. Most of the polysaccharides were removed effectively in a single high-salt precipitation at 1.0-2.5 M NaCl. At 3.0 M NaCl, the salt precipitated out of solution. Purified DNA was easily digested by either HindIII or EcoRI and was satisfactory as a template for PCR. The results show that high-salt precipitation effectively removed polysaccharides and their inhibitory effects on restriction enzyme and Taq polymerase activity.


DNA cassettes containing the origin of transfer (oriT) of two broad-host-range transfer systems. Plasmid constructs are described that carry retrievable DNA cassettes containing the origin of transfer region (oriT) from two broad-host-range plasmids. Restriction of these high copy number plasmids with any one of a variety of enzymes yields a linear DNA fragment of convenient size containing the oriT region of either pCUI or RK2. This DNA can be ligated into any vector or recombinant plasmid containing a compatible enzyme site and can be easily identified by size on an agarose gel. Any plasmid can therefore be mobilized using a number of helper strains or conjugative plasmids derived from the parental plasmids. In addition, the cassettes can be used for a variety of genetic manipulations including "selectable" linker mutagenesis.


Magnesium-dependent thermostability of DNase I. DNase I can be used to remove contaminating DNA from RNA samples. Heat treatment has been recommended as a method to inactivate DNase I enzymatic activity, thereby allowing subsequent reverse transcription and PCR amplification of DNase I treated RNA. We have found that inactivation of DNase I by heat treatment is strongly dependent on Mg2+ concentration. In addition, deoxyribonucleolytic activity of "inactivated" enzyme may be restored by changes in Mg2+ concentration following heat treatment. Caution should be exercised when using heat treatment alone as a method of DNase I inactivation.


Cloning and direct sequencing of plant promoters using primer-adapter mediated PCR on DNA coupled to a magnetic solid phase. A method that allows amplification and direct sequencing or cloning of an unknown DNA segment flanked by a known sequence is described using barley genomic DNA. The method avoids the step of circularization necessary for inverse PCR by ligation of primer-adapters to restricted genomic DNA. Specificity is achieved in the first amplification step; linear PCR with a biotinylated primer complementary to the known flanking sequence (primer 1-B) produces a single-stranded product that is purified employing streptavidin-coated magnetic beads. After this step, which removes genomic DNA, two rounds of exponential PCR are performed, first with the adapter-primer and primer 1 and second with primer 1 substituted by a nested primer 2. If the second primer is biotinylated, the product can be sequenced directly using solid-phase sequencing. We have employed this method to sequence directly and to clone the promoters of two late embryogenesis-abundant (Lea) genes (B19.4 and B19.3) from barley. Lea B19.4 and B19.3 encode putative desiccation-protective proteins that act in the final stages of embryogenesis and have previously been cloned as cDNAs. We demonstrate here that their proximal promoter regions are very similar (80% identity) and that both contain putative abscisic acid-responsive elements.


Direct sequencing of baculovirus genomic DNA: sequence determination of the engineered respiratory syncytial virus chimeric FG gene. Primer-directed enzymatic sequencing has proven to be an efficient and effective method for sequencing various size double-stranded DNA templates. We previously developed a primer-directed sequencing procedure for using double-stranded cosmid (50 kb) DNAs as template. We are interested in using this method to directly sequence larger DNA templates. Towards this goal we applied this method to directly sequence an engineered gene that had been transferred and integrated into the 130-kb baculovirus genome. Both crudely prepared and CsCl gradient-banded baculovirus DNAs were tested and reasonable sequencing ladders were obtained for both types of DNA templates. As little as 3 micrograms of gradient-banded baculovirus DNA were found to be sufficient to obtain film exposure times similar to those observed for cosmid size templates, 24 to 48 h. Effectiveness of the described method was demonstrated by obtaining the complete sequence of the engineered respiratory syncytial virus chimeric FG gene (2.5 kb in length) directly from the recombinant baculovirus "Baculo-FG" genome. Thus, our results demonstrate first, that double-stranded DNA templates as large as 130 kb can be sequenced directly and second, that the nucleotide sequence of engineered genes integrated within the baculovirus genome can be determined without the use of any intermediate steps of procedures.


Localization of bFGF mRNA in cyclic rat ovary, diethylstilbesterol primed rat ovary, and cultured rat granulosa cells. Evidence from in vitro studies strongly implicates basic fibroblast growth factor (bFGF) as a local regulator of ovarian function. However, the in vivo function of this growth factor in the ovary is uncertain. The objective of this study has thus been to investigate the biological role of bFGF in the rat ovary by monitoring bFGF gene expression using in situ hybridization in 3 systems; (1) the naturally cycling ovary, (2) ovaries of immature rats treated with diethylstilbesterol (DES), and (3) primary rat granulosa cell cultures. The rat estrus cycle can be divided into 4 stages as determined by vaginal cytology; diestrus, proestrus, estrus and metestrus. bFGF mRNA transcripts were localized to granulosa and theca cells of developing follicles during proestrus and estrus and in the corpus luteum following ovulation during metestrus. The estrogen analogue DES induced extensive in vivo folliculogenesis and high levels of bFGF mRNA in both granulosa and theca cells when compared to controls. Detectable levels of bFGF mRNA were also observed in primary granulosa cell cultures grown to high density. Employment of this in situ hybridization procedure has enabled the in vivo cellular sources of bFGF mRNA to be identified and the time course of expression during the estrus cycle to be monitored. The biological significance of this expression and the interplay between bFGF, extra- and intra-ovarian modulators are discussed.


Inhibition of differentiation in a murine F9 embryonal carcinoma cell subline by leukemia inhibitory factor (LIF). Leukemia inhibitory factor (LIF) is a cytokine previously shown to maintain pluripotent embryonic stem cells in their undifferentiated state. We have examined the effects of LIF in nullipotent embryonal carcinoma cell lines, and have found that LIF blocks differentiation induced by retinoic acid and at low temperature in OTF9 cells. LIF did not block differentiation in a parent F9 cell line. For OTF9 cells, LIF acts early in differentiation, inhibiting the appearance of parietal endoderm-type product cells. However, it acts subsequent to retinoic acid, and at least one early retinoic acid-induced event is unaltered in the presence of LIF. This finding provides both a means of dissecting the cascade of events leading to EC cell differentiation, and a well-characterised target cell type for studying the mechanism of action of LIF.


Transforming growth factor e: amino acid analysis and partial amino acid sequence. Our previous studies have demonstrated that transforming growth factor e (TGFe) acts as a mitogen for epithelial and fibroblastic cells in both monolayer and soft agar. We have also identified TGFe in both normal and neoplastic tissues of mostly epithelial origin, and in body fluids. In this study we report on the purification of TGFe to homogeneity from bovine kidney using a multistep purification protocol which utilizes high performance electrophoresis chromatography in the final step. Amino acid analysis of TGFe revealed high content of proline, aspartate and glutamate. Examination of partial amino acid sequence indicated no similarity to other, already characterized, growth factors.


[Ibopamine in the treatment of congestive heart failure. Multicenter follow-up study]. To assess safety and efficacy of ibopamine, 200 mg TID, added to conventional treatment of congestive heart failure. A prospective, longterm, open study over two years (1986-88). A multicenter trial. Outpatients of Departments of Internal Medicine of S. Francisco Xavier Hospital and Sta. Maria Hospital, and Departments of Cardiology of Sta. Cruz Hospital and Hospital Militar Principal, Lisbon. 63 patients, 49 males from 34 to 80 years (m = 55.6 +/- 11.36) and 14 females from 41 to 80 years (m = 63 +/- 10.2), with congestive heart failure, NYHA class II in 52 patients (82.5%) and NYHA class III in 11 patients (17.5%) with a mean disease duration of 47.9 months entered into the study. Digoxin, diuretics, nitrates and antiarrhythmic drugs were allowed as concomitant therapy. Patients carried out clinical examination, ECG and laboratory tests monthly and X-Ray at the beginning and at the end of each year of the study. 42 patients completed one year of treatment and 20/42 continued for an additional year, 17 patients completed this second year of follow-up. From the 42 patients who completed the first year period, the NYHA class changed from II to I in 17/38 from II to III in 2/38 patients from III to II in 3/4 patients, and from III to IV in one patient. Twenty patients dropped during the first year of treatment. Six for non-compliance (less than 80% of the treatment). Two were submitted to cardiac valve surgery. Seven had cardiovascular clinical events: one ventricular tachycardia, one atrial fibrillation, one pulmonary edema, one patient had no therapeutic effect, two patients had anxiety and fatigue and one patient died suddenly. One diabetic patient had uncontrolled hyperglycemia. One patient had gastric ulcer. Two had nausea and vomiting. Dysrhythmia and nausea and vomiting were the only clinical events, considered, respectively, possibly related and related, to ibopamine. During the second year of treatment 9/11 patients were stabilized in NYHA class I and 6/9 in NYHA class II, one patient changed from class II to class I, and one patient changed from class I to class II of the NYHA. Three patients did not complete the second year of treatment; one due to abnormal creatininemia; one for probable pulmonary embolism with CHF worsening; the third died suddenly. None of these events was considered related to ibopamine. Heart rate, arterial pressure, laboratory values and cardiothoracic index did not vary over the two years of the study. This has been the first study with data from patients treated with 200 mg TID of ibopamine during two years. Ibopamine has been shown to be a safe and useful drug added to conventional treatment of cardiac heart failure. Clinical events were few and well controlled after ibopamine interruption.


[Evaluation of the aerobic capacity of blind people, by direct VO2 maximal measurement]. Physical activity is the basic factor to the human being in order to assume his place in society. Blind persons are often sedentary, which compromises its physical capacity. The present work evaluates the blind person's physical capacity, analysing possible differences related to sex, age and life time blindness. The sample was constituted by 27 blind (congenital and noncongenital), 18 male and 9 female, aged between 17 and 37 years old. To evaluate previous physical activity, a questionnaire, was answered which showed a dominant sedentary population. The maximum oxygen uptake was determined in a treadmill test using standard procedures (Bruce protocol). Medium results for boys were 45.85 +/- 8 ml/kg/min and for girls were 34.46 +/- 3.8 ml/kg/min. The difference between congenital and acquired blindness on the VO2max values was 2.9 ml/kg/min, not statistically significant (p = 0.468). Those findings lead us to consider that aerobic capacity mostly depends on type and intensity of physical exercise which may be temporary related to the onset of blindness and visual impairment degree.


[Changes in the physiologic pattern of mitral prosthesis regurgitation in the presence of a prosthetic dysfunction]. Evaluation by transesophageal echocardiography of the effect on the characteristics of physiological regurgitant jets (JF) resulting from prosthetic disfunction due to pathologic regurgitation (JF). We studied 69 consecutive patients with the diagnosis of prosthesis in mitral position using transesophageal echocardiography and color doppler codification. The patients were divided in two groups (N and D groups) according to the presence of prosthesis disfunction by pathologic regurgitation. In each patient we determined planimetric areas and atrial peak depth of each JF and also the sum of JF planimetric areas of each mitral prosthesis. When pathological regurgitation was present we calculated the highest planimetric area, severity degree and atrial peak depth in each JP. The planimetric area in each JF of group N was 330 +/- 167 mm2 and in group D 117 +/- 116 mm2 (p less than 0.001). The sum of the areas of JF in group N was 474 +/- 204 mm2 and in group D 254 +/- 176 mm2 (p less than 0.01). The atrial depth of JF in group was 32 +/- 15 mm and in group D 26 +/- 18 mm (p less than 0.01). In group D 29% of the patients had mild pathological regurgitation, 10% moderate and 61% severe. The maximum planimetric area of JP in group D was 1078 +/- 1007 mm2 with atrial depth of 37 +/- 28 mm. The pathological regurgitation in disfunction prosthesis in mitral position has a significant reduction effect in the dimension of prosthesis physiologic regurgitation jets. This transesophageal echocardiographic observation makes it possible to characterize and clarify more precisely the different types of mitral prosthesis jets.


[Coronary atherosclerosis in acute myocardial infarct. Anatomic profile of diverse causes of death]. to study the degree of coronary obstruction by atherosclerotic plaques in a population dying with acute myocardial infarction. We defined subgroups by the degree of the obstructive lesion and compared the severity and distribution of coronary atherosclerotic lesions in different groups according to cause. systematic prospective study in patients dying in the acute phase of myocardial infarction in a University Hospital Coronary Unit during a four years period. we studied 193 patients corresponding 77% of the patients dead in the same period. 24 patients were excluded by technical reasons related to the preparation of necropsic material. The clinical protocol included 64 parameters and were considered the following causes of death: left ventricular failure (shock or acute pulmonary edema), left ventricular free wall rupture, interventricular septum rupture, primary asystole, pulmonary embolism and ventricular fibrillation. To study of the heart we performed the transverse slices technic after fixation; to study the epicardial coronary arteries we isolated the coronaries after fixation and made 5 mm transverse slices. The slices were macroscopic and microscopic evaluated for the degree of coronary obstruction in every 5 mm segment. We classified the degree of coronary obstruction in five grades: less than or equal to 25%; greater than 25% e less than or equal to 50%; greater than 50% e less than or equal to 75%; greater than 75% e less than 100%; and total obstruction. the degree of coronary obstruction in each epicardial segment were: Right ostium--grade I = 21%, grade II = 46%, grade III = 26%, grade IV = 7%, grade V = 0; Right coronary--grade I = 5%, grade II = 10%, grade III = 19%, grade IV = 28%, grade V = 38%; Left ostium--grade I = 27%, grade II = 50%, grade III = 19%, grade IV = 4%, grade V = 0; Left main--grade I = 16%, grade II = 43%, grade III = 28%, grade IV = 10%, grade V = 2%; Anterior descendent--grade I = 1%, grade II = 5%, grade III = 11%, grade IV = 34%, grade V = 49%; Left circumflex--grade I = 2%, grade II = 14%, grade III = 22%, grade IV = 40%, grade V = 22%. The number of coronary arteries with more than 75% obstruction for each group of one, two or three vessel disease were: 1 vessel--41 cases; 2 vessels--56 cases; 3 vessels--68 cases. The number of vessels with more than 75% obstruction for each cause of death were: Wall rupture--1 vessel = 20, 2 vessels = 18, 3 vessels = 11; Septum rupture--1 vessel = 0, 2 vessels = 2, 3 vessels = 2; Shock--1 vessel = 12, 2 vessels = 21, 3 vessels = 30; Acute pulmonary edema--1 vessel = 1, 2 vessels = 9, 3 vessels = 7; Asystole--1 vessel = 4, 2 vessels = 1, 3 vessels = 8; Pulmonary embolism--1 vessel = 2, 2 vessels = 5, 3 vessels = 8; Ventricular fibrillation--1 vessel = 2, 2 vessels = 0, 3 vessels = 2. in most patients dying with acute myocardial infarction, the coronary atherosclerotic lesions were present in two or three epicardial coronary arteries. The left anterior descendent artery was the more frequent artery with major lesion (greater than 75%). Major atherosclerotic lesion in just one vessel were more frequent in patients dying by cardiac rupture.


[Effect of converting enzyme inhibitors in cardiac insufficiency mortality in the elderly]. In a retrospective study we analyse two populations of aged patients in congestive heart failure, one treated with ACE inhibitors other not and the other with conventional therapy. Both populations received the same medication (diuretics and digitalis) and are equivalent in age, sex distribution, NYHA functional class and echocardiographic left ventricular parameters. Comparing the mortality of the two populations at the first, second and third year of follow-up, a statistically significant reduction in mortality was found on the ACE inhibitors treated population, at the first year. However, this reduction did not reach statistical significance at second and third years. The results are similar to trials in which the effects of ACE inhibitors are studied on general populations in heart failure.


[A case of incessant junctional tachycardia in a female patient with aneurysm of the interauricular septum]. A permanent supraventricular tachycardia (SVT) was diagnosed in a 54-year-old hypertensive but cardiologically asymptomatic female patient, admitted to a surgery department for biliary lithiasis and hepatic echinococcosis. Heart rate was about 130 bpm and ECGs showed negative P waves in leads I, II, III, aVF, and precordial leads V2 to V6, being the RP' interval longer than P'R interval. Pharmacological intervention during Holter monitoring (20 hours) was instituted: following i.v. propranolol (4 mg), heart rate progressively decreased (to 112 bpm), mainly due to an increase in SVT RP' interval, and brief, spontaneous SVT interruptions occurred, preceded by P'R interval prolongation; SVT stopped after P' recording, and resumed after 2 sinus beats, (showing enlarged P waves and slightly prolonged PR interval), induced by cycle length shortening; later on, under i.v. amiodarone infusion (100 mg/hour) and coincident with the sleeping period, SVT cycle length progressively increased (to 600 msec), due to equivalent increases in P'R and R'P intervals. Two premature ventricular contractions (PVC) occurred during Holter monitoring at a coupling interval of 80-85% of SVT cycle length (480 msec): one PVC apparently originated in left ventricle lateral wall, captured the atria, which were activated 75 msec earlier than expected; the other PVC, apparently originated in left ventricle septoapical region, did not interfere with SVT cycle length. Before these data, a diagnosis of circus movement tachycardia, incorporating a concealed accessory pathway with slow retrograde conduction and ventricular insertion in the postoroseptal or left posterior paraseptal region, and showing minor impairment of antegrade AV nodal conduction, was made. Invasive electrophysiological study was then discarded. With combined oral antiarrhythmic therapy (amiodarone, 600 mg/d), plus propafenone, 450 mg/d), sinus rhythm was permanently restored, with evidence of intraatrial block, slightly prolonged PR interval and no preexcitation. Transesophageal echocardiography revealed a small atrial septal aneurysm associated with a small atrial septal defect; echocardiographic features were consistent with the hypothesis of incomplete regression of the atrial septal aneurysm after partial closure of the atrial septal defect. Abdominal surgery (cholecystectomy plus partial hepatic pericystectomy) was performed without any complications or SVT recurrences. During a 6-month follow-up period, maintaining amiodarone (200 mg/d) and propafenone (450 mg/d), the patient remained SVT-free, and Holter monitoring performed at 3 and 5 months showed permanent sinus rhythm and 1:1 AV conduction with slightly prolonged PR interval (less than 0.29 sec and shortening at faster heart rates). This case documents Holter monitoring capability for the evaluation of tachycardia mechanisms in patients with permanent SVT.


[Civil aviation and cardiology. Admission rules and follow-up of the technical flying personnel of TAP-Air Portugal]. The authors, based in European and American rules, consensus positions of Clinical Aerospace Congresses and their own experience, marked admission and follow-up rules of conduct for TAP Air Portugal aircrew. They stressed the importance of modern technology in arterial pressure ambulatory diagnosis and pointed the necessity of arterial pressure treatment in the other cardiovascular risk factors context. They relief ischemic myocardial disease because it is incompatible with flying safety, even in those submitted to coronary angioplasty or bypass graft surgery. For those with arrhythmias, valvular heart disease, myocarditis, cardiomyopathy and adult life congenital heart disease, we emphasize admission and follow-up rules.