The three syndromes of fat embolism: pulmonary manifestations.

The clinical course and radiographs of 30 patients with fat embolism syndrome were reviewed. In all cases the classic triad of neurologic dysfunction, respiratory insufficiency, and petechiae were present. Three responses to embolized fat were noted. The hyperacute response was seen in two patients with paradoxical embolization of fat to the systemic circulation. A "classic response" was noted in 18 patients with transient respiratory compromise and variable radiographic findings. The two deaths in the group responding in the classical manner were attributed to massive pulmonary emboli. The third response, noted in ten patients, consisted of a chest radiograph compatible with pulmonary edema in the clinical setting of the adult respiratory distress syndrome. In this group the degree of respiratory dysfunction and pulmonary damage correlated with the development of disseminated intravascular coagulation. Pathologic correlations are presented and the mechanisms by which embolic fat produces tissue damage are discussed.     

The treatment of chronic osteomyelitis with clindamycin

Clindamycin was given orally over prolonged periods to 12 patients with chronic osteomyelitis. It was well tolerated with only minor side effects and no major toxicity. Clinical and bacteriological cure occurred in five patients and improvement was noted in another five. It appears less effective than either lincomycin or cloxacillin but, because of the complex nature of both the disease and its treatment, strict comparisons are very difficult.     

Ultrasound; its effect on the cardiovascular system when applied over the carotid sinus and stellate ganglion

In a study of 29 patients to observe untoward reactions to applications of ultrasound over the carotid sinus and stellate ganglion areas, it was noted that cough was evoked in five patients, premature ventricular systoles in three and a burning sensation of the skin at the point of treatment in five. No considerable effect on heart rate or blood pressure was observed.     

ULTRASOUND—Its Effect on the Cardiovascular System When Applied Over the Carotid Sinus and Stellate Ganglion

In a study of 29 patients to observe untoward reactions to applications of ultrasound over the carotid sinus and stellate ganglion areas, it was noted that cough was evoked in five patients, premature ventricular systoles in three and a burning sensation of the skin at the point of treatment in five. No considerable effect on heart rate or blood pressure was observed.     

The Effects of Thiethylperazine Dimaleate (Torecan) on Nausea and Vomiting

A double-blind study of thiethylperazine dimaleate (Torecan) and a placebo, given intramuscularly, was carried out on 40 patients with nausea and/or vomiting due to a variety of causes. No effect on these symptoms was noted in five patients who received the drug and in six who received the placebo. Thiethylperazine dimaleate was judged to have a good effect in 14 patients and the placebo in five patients. The placebo had a slight effect in nine patients and the drug in one.     

Splenic Subcapsular Hematoma—Ultrasonic Diagnosis

In five patients with varying histories of blunt abdominal trauma, examinations were carried out with ultrasonography and other imaging modalities. In all five patients, large, fluid-filled masses were noted in the left upper quadrant. Two patients had nonpalpable hematomas, but examinations were done because of history and vague clinical symptoms. Three patients had palpable masses. In all five patients there was surgical confirmation of the ultrasonic findings, and all recovered without complications. Ultrasonic tomography offers a convenient noninvasive method for assessing suspected splenic hematoma and can also exclude the possibility in a careful examination.     

The spectrum of intermediate syndrome following acute organophosphate poisoning: a prospective cohort study from Sri Lanka

Background

Intermediate syndrome (IMS) is a major cause of death from respiratory failure following acute organophosphate poisoning. The objective of this study was to determine repetitive nerve stimulation (RNS) predictors of IMS that would assist in patient management and clinical research.

Methods and Findings

Seventy-eight consenting symptomatic patients with organophosphate poisoning were assessed prospectively with daily physical examination and RNS. RNS was done on the right and left median and ulnar nerves at 1, 3, 10, 15, 20, and 30 Hz. The study was conducted as a prospective observational cohort study in the Central Province, Sri Lanka. IMS was diagnosed in ten out of 78 patients using a priori clinical diagnostic criteria, and five of them developed respiratory failure. All ten patients showed progressive RNS changes correlating with the severity of IMS. A decrement-increment was observed at intermediate and high frequencies preceding the onset of clinical signs of IMS. As the patient developed clinical signs of IMS, decrement-increment was progressively noted at low and intermediate frequencies and a combination of decrement-increment and repetitive fade or severe decrement was noted at high frequencies. Severe decrement preceded respiratory failure in four patients. Thirty patients developed forme fruste IMS with less severe weakness not progressing to respiratory failure whose RNS was characterized by decrement-increment or a combination of decrement-increment and repetitive fade but never severe decrements.

Conclusions

Characteristic changes in RNS, preceding the development of IMS, help to identify a subgroup of patients at high risk of developing respiratory failure. The forme fruste IMS with the characteristic early changes on RNS indicates that IMS is a spectrum disorder. RNS changes are objective and precede the diagnosis and complications of IMS. Thus they may be useful in clinical management and research.     

Effect of oxidants and antioxidants on chromosomal breakage in Fanconi anemia lymphocytes

Summary Peripheral blood lymphocytes from eight Fanconi anemia (FA) patients, 14 FA heterozygotes, and nine normal subjects have been tested for their susceptibility to chromosomal breakage induction by diepoxybutane (DEB) and by two peroxides. In addition, the effect of five antioxidants was investigated in standard cultures and in cultures stressed either with DEB or with butylhydroperoxide (BHP) or with hydrogen peroxide (H₂O₂). DEB, BHP, and H₂O₂ dramatically increased the chromosomal breakage levels in homozygous and heterozygous FA cells. A partial correction of chromosomal instability was obtained by treating the patients' lymphocytes with antioxidants. A protective effect was also noted in the DEB or peroxide-stressed lymphocytes of patients and heterozygotes, grown in the presence of antioxidants.     

Restenosis Following Mitral Valvoplasty

Nineteen seriously disabled patients were operated upon a second time (using closed-heart technique) for recurrence of symptoms of mitral stenosis. The hospital mortality rate was 10.5%; there was one late death. Ten patients (52%) were well and working six months to five years after the second operation. In considering the cause of restenosis it was noted that nine patients had inadequate opening of the mitral valve at first operation. In five cases (26%) rheumatic activity appeared to be solely responsible for restenosis. In a further four cases (21%) it was considered that rheumatic activity was a contributing cause of restenosis. The diagnosis of rheumatic activity and the place of open heart procedures in the treatment of restenosis are discussed.     

The ‘World Prodigy’ oil spill in Narragansett Bay,Rhode Island: acute effects on macrobenthic crustacean populations

On June 26,1989, the tanker World Prodigy ran aground just outside the mouth of the West Passage of Narragansett Bay, Rhode Island, USA. About 922 metric tons of No. 2 fuel oil were released into the water and drifted over a total area of about 120 sq miles. Three days after the spill only a small fraction of the oil remained.The effects on macrobenthic crustaceans within the first five weeks after the spill were studied at five stations with a varying degree of oil exposure, including one control site never reached by oil from the spill. Significant differencies between these stations were noted for total amphipod abundance, the amphipod genus Ampelisca and ostracods (retained on a 0.3 mm mesh), but not for amphipods of the genus Corophium. At the most heavily impacted station (23 µg oil g^–1 sediment dry weight), the total amphipod abundance, dominated by Ampelisca verrilli, decreased by 86% within the first two weeks after the spill. Decreases in total amphipod abundance significantly larger than at the control site were noted also at two other stations, one of which with only trace amounts of oil detected in the sediment. The amphipod populations at these sites were dominated by juvenile specimens.These findings confirm the extreme sensitivity to oil pollution of amphipods and ostracods, noted in earlier field and experimental studies.     

Circadian rhythms of electrolyte and 17-hydroxycorticosteroid excretion in hyperthyroidism and hypothyroidism.

The circadian rhythms of excretion of sodium, potassium, calcium, magnesium, phosphorus and 17-hydroxycorticosteroid (17-ohcs) were determined in five normal subjects, in six patients with hyperthyroidism and five with hypothyroidism. Constant diets with identical 3-hourly feedings were employed, and urine collections were made every 3 hrs during a 3-day study period. The circadian patterns of urinary excretion of sodium, potassium and 17-OHCS were similar in all three groups with distinct daytime peaks and nighttime nadirs. The total quantities of the ions and 17-OHCS excreted were greater in hyperthyroid than in hypothyroid patients with the greatest difference noted with the 17-OHCS. The rhythms for calcium, magnesium and phosphorus excretion were accentuated in hyperthyroid patients but similar to those in normal subjects with early morning calcium and magnesium peaks and a phosphorus peak approximately 12 hrs later. While a similar although blunted circadian pattern for calcium and perhaps magnesium excretion was noted in hypothyroid patients, their phosphorus rhythms were distorted and rather flat. These latter results confirm the observation of MINTZ et al. and are compatible with their interpretation that thyroid hormone is permissibly necessary for the expression of a normal phosphaturic rhythm and that the circulating level of thyroid hormone influences the amplitude of the phosphaturic rhythm.     

The Use of Hypnosis in the Treatment of Exhibitionism

The use of hypnosis in the treatment of exhibitionism is described in three patients in whom the condition had been present for more than five years. In each patient there was no subsequent recurrence of the exhibitionism once therapeutic suggestions had been made in a deep hypnotic trance, the follow-up period being respectively five years, four and a half years, and one year.The method of treatment and the results are discussed in terms of the concepts of behaviour therapy.It is concluded that with certain patients suffering from exhibitionism the use of hypnosis may well be one of the best methods of treatment, but considerable care should be exercised to exclude those patients with an underlying psychosis, mental defect or psychopathic condition. It is also noted that the efficacy of the treatment would appear to depend on achieving a satisfactory depth of hypnotic trance. If this is not reached, the results are less likely to be successful.     

A comparative study on the dental health status of five precolumbian Peruvian cultures.

In a survey of dental health status of ancient Southern Peru, 101 skeletal remains were studied from five cultures: Paracas, Nazca, Tiahuanaco, Ica, and Inca. The Paracas and Ica cultures exhibited more missing antemortem teeth per mandible than the other cultures. Frequency of missing one or more third molars was less than expected and not as high as reported in peoples of Mongoloid heritage. The Paracas, Ica and Nazca, "coastal" cultures had a higher caries incidence than the "inland" cultures. Whether this relates to some difference in diet or water supply remains unresolved and warrants further investigation. Moderate attrition was noted in all the Precolumbian cultures but pulpal involvement was not observed. Osteitis, noted in all the cultures, was more pronounced in the Nazca, Paracas and Ica cultures. There appeared to be a direct relationship between caries involvement and the number of missing antemortem teeth to osteitis. Calculus was heavier in the Paracas and Ica cultures. In addition, the Paracas culture exhibited a dark brown stain on the teeth which may imply some difference between the cultures in either the food, water or social habits.     

The effects of staphylococcal protein A on human lymphokine-activated killer cell induction

Summary A murine IgG2b monoclonal antibody directed to the constant part of the human / T cell receptor (BMA031) was investigated in a pilot study as an initial treatment for acute graft-versus-host disease (aGvHD) after allogeneic bone marrow transplantation. The treatment protocol consisted of 5 mg BMA031 on 5 consecutive days with continuation of the prophylactic baseline immuno suppression using cyclosporin. Seven patients with grades II–III acute graft-versus-host disease were entered on the protocol and six patients completed the full treatment course. Mild to moderate acute adverse reactions to the first BMA031 infusion occurred in three patients. A nearly complete decline of circulating T lymphocytes was observed during BMA031 therapy, but the T cells returned to pretreatment values within 1 week after the last infusion. Serum pharmacokinetics of free antibody best fitted to a two-compartment open model with a mean initial half-life of 6 h and an estimated mean terminal half-life of 40 h. One patient developed antimurine antibodies of the IgM subclass. In five patients a complete and sustained resolution of all disease manifestations was attained, while in one patient a temporary response of skin involvement with aGvHD was noted. These results indicate that BMA031 can be safely administered as initial treatment of aGvHD. The therapeutic responses observed warrant its further clinical evaluation in this setting.     

Double labeling and in vitro versus in vivo incorporation of bromodeoxyuridine in patients with acute nonlymphocytic leukemia

A monoclonal antibody against bromodeoxyuridine (BrdUrd) was produced, and a rapid slide technique (RPMB technique) was developed for the estimation of S-phase cells in a population using this antibody. Bone marrow cells from patients with acute nonlymphocytic leukemia (ANLL) were studied by both the RPMB technique and tritiated thymidine (3HdThd) labeling index studies. The percentage of S-phase cells obtained by each method was compared in 50 samples, and the correlation coefficient was r = 0.89. A "double label" method is also described in which cells were simultaneously incubated with either BrdUrd and 3HdThd or BrdUrd and tritiated cytosine arabinoside (3HAra-C). The samples were first processed by the RPMB technique and then by autoradiography. Results showed only black grains overlying the nuclei of fluorescent cells in each group. An automated microphotometer was used to quantitate grains and fluorescence from each cell. This demonstrated an almost direct relationship between grains and fluorescence from BrdUrd + 3HdThd slides, whereas different patterns of relationship were noted from BrdU + 3HAra-C slides of leukemic patients. Their implications are discussed in the text. Finally, intravenous infusions of BrdUrd was given to five leukemic patients. S-phase cells were recognized distinctly within 5 min of starting the infusion. The percentage of S-phase cells was almost identical from in vivo and in vitro samples. Various possibilities of studying the biological behavior of acute leukemias and analyzing cell cycle characteristics are discussed.     

Biochemical changes in rat liver after 18.5 days of spaceflight

The effect of "weightlessness" on liver metabolism was examined using tissue from rats flown in earth orbit for 18.5 days aboard the Soviet Cosmos 936 biosatellite. Changes in the activities of certain carbohydrate and lipid enzymes were noted. Of the 28 hepatic enzyme activities assayed, two, palmitoyl-CoA desaturase and lactate dehydrogenase, increased, whereas five, glycogen phosphorylase, 6-phosphogluconate dehydrogenase, both acyltransferases which act on alpha-glycerolphosphate and diglycerides, and aconitate hydratase decreased. The remaining enzyme activities measured were unchanged. In addition, increased levels of liver glycogen and palmitoleate were noted which probably resulted from the lowered glycogen phosphorylase and increased palmitoyl-CoA desaturase activities, respectively, in those animals that experienced weightlessness. These changes caused by weightlessness were transient since all of the aforementioned alterations returned to normal values when measured in the livers of other rats which had flown in the biosatellite 25 days after recovery.     

Effects of Clonidine Withdrawal: Possible Mechanisms and Suggestions for Management

A severe rebound rise in blood pressure with agitation and insomnia had been noted in five patients when they had previously ceased clonidine (Catapres) This has been shown to be reproducible in these patients and to be associated with a significant increase in urinary catecholamine excretion. The blood pressure can be controlled and the symptoms alleviated promptly by alpha and beta adrenergic receptor blockade using intravenous phentolamine and propranolol.     

Five years of heartsink patients in general practice.

"Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour. A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them. As a group they were often in employment and in stable relationships, though women were over represented. Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period. While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice. Heartsink as a phenomenon has features that are unique to general practice.     

Acid Secretion and Serum Gastrin Levels in the Zollinger-Ellison Syndrome

Thirteen cases of patients with the Zollinger-Ellison syndrome were reviewed. In two cases the diagnosis was made by incidental biopsy of small liver nodules at operation for peptic ulcer disease.Seven patients had gastric secretory tests which showed a basal acid output to maximum acid output ratio of more than 65 percent. Five patients had bao:mao ratios less than 50 percent.A 30-month interval between incidental discovery of tumor and clinically evident disease was observed in two patients. Recurrence of symptoms after excision of tumor was noted after a similar interval in another case.Serum gastrin levels, before total gastrectomy, were elevated in all cases. The lowest preoperative level in this series of patients was 550 picograms per ml (normal 100 to 150 picograms). They were diagnostic in two patients with normal gastric secretory studies. The levels fell to normal following total gastrectomy in six patients. Two patients still had elevated levels five years and 14 years after total gastrectomy. One was discovered to have a parathyroid adenoma with hypercalcemia.Total gastrectomy was curative in all the patients with the Zollinger-Ellison syndrome; lesser operations were not.     

Titration of natural and disease-related cytotoxicity of lymphocytes from bladder cancer patients

Summary A controlled investigation of lymphocyte-mediated cytotoxicity has been carried out in patients with transitional cell carcinoma (TCC) of the urinary bladder, three long-term established cell lines with comparable sensitivities to the natural cytotoxicity (NC) being used as targets, namely HU 456 derived from human TCC, HU 609 from normal human urothelium, and SAOS 2 from a human osteosarcoma. The 44-h incubation microcytotoxicity assay (MA) was used with blinded semiautomatic visual counting of target cells. The cytotoxicity was determined by titration with a serial dilution of lymphocyte suspensions 1:2, five different concentrations being used in each experiment. Fifty tests were performed with lymphocytes from 48 TCC patients. As controls, 65 patients with diseases other than TCC were tested simultaneously. The average cytotoxicity of lymphocytes from TCC patients against HU 456 was only slightly and insignificantly higher than that of the control patients. However, a marked decrease of the NC against the control cells HU 609 and SAOS 2 was noted with TCC patient lymphocytes.After correction of the data for the depression of background NC, increased tumor-specific cytotoxicity (TSC) and tumor type-specific cytotoxicity (TTSC) were demonstrated in TCC patients with noninvasive malignant tumors (grade 2 or 3), whereas no increased specific cytotoxicity was found in TCC patients with invasive grade 2 or 3 tumors. Neither was any increased specific cytotoxicity found in patients with very well-differentiated grade tumors. The presence of specific reactivity in patients with noninvasive TCC in contrast to invasive TCC is supposed to indicate growth-controlling function of the cellular immune reaction.Tests were also performed with lymphocytes from 35 patients in the postoperative phase without any history of TCC. Surprisingly, this group revealed a significantly elevated TSC but not increased TTSC when compared with the 65 untreated control patients, thus indicating that serious reservations must be made in the interpretation of the cytotoxocity assay.