[Analysis of fatal outcomes of meningococcal infection in adults].

Clinical characteristics and pathomorphological manifestations in 69 patients aged 18 to 86 years with a fatal outcome of the disease were examined in order to analyze the causes of severe course and high mortality of generalized forms meningococcal infection. It was found that the main clinical form was meningococcemia (90%), in the majority in combination with meningitis (52%). The fulminant course in 77% of patients with meningococcal sepsis manifested itself as a sudden onset, rapid development of typical symptoms. Hemorrhagic exanthema was detected on the first day of meningococcemia. The leading complications and critical conditions were infectious-toxic shock, disseminated intravascular coagulation and acute adrenal insufficiency (Waterhouse-Friederiksen syndrome). The severe course of meningitis (in 10%) led to the development of cerebral coma, the morphological substrate of which was edema - swelling of the brain.

[Pathological anatomy of tuberculosis in the presence of human immunodeficiency virus infection]. / Patologicheskaia anatomiia tuberkuleza na fone infektsii, vyzvannoi virusom immunodefitsita cheloveka.

Tuberculosis occupies a leading position among secondary infections in the structure of mortality in HIV-positive patients. Moreover, the concurrence of these diseases frequently makes a morphological diagnosis most difficult due to the atypical course of tuberculosis (TB) in the presence of immunosuppression. AIM: to assess the clinical and morphological characteristics of concurrent TB/HIV infection. MATERIAL AND METHODS: An autopsy material obtained from the S.P. Botkin Clinical Infectious Diseases Hospital (CIDH) in 2018 was analyzed. Eight samples stained with hematoxylin and eosin, Ziehl-Neelsen carbol-fuchsin, auramine-rhodamine were thoroughly examined, followed by fluorescent microscopy; an immunohistochemical (IHC) study was performed. RESULTS AND DISCUSSION: 736 autopsies made at the S.P. Botkin CIDH in 2018 revealed 357 deaths from HIV infection; 86 (24%) cases of which were caused by concurrent HIV/TB infection. All the cases showed an extremely diverse and heterogeneous pattern that considerably differed from that of classical granulomatous inflammation in tuberculosis. Ziehl-Neelsen staining could demonstrate single clusters of acid-resistant bacteria with a total of not more than 1000 in the specimen of predominantly rod-shaped bacteria. Auramine-rhodamine staining revealed focal clusters of mycobacteria with a total of 1000 to 2000 in the specimen of predominantly rod-shaped and coccoid bacteria. An IHC study identified clusters of mycobacteria with a total of more than 2000 in the sample, which were characterized by a moderate variety of shapes: rods, cocci, granules, clavate, and branched ones. Mycobacteria were present extracellularly in all the studied cases. CONCLUSION: Tuberculosis holds the most important place in the pattern of causes of death in HIV infection, accounting for 24%. The lifetime diagnosis of tuberculosis remains not entirely satisfactory. The alterative component of inflammation more often predominates, although without completely losing the ability to form granulomas. The concurrence of different morphological forms of tuberculosis makes it highly desirable to clarify and/or supplement the existing classifications. None of the methods used to detect Mycobacterium tuberculosis in the tissues could reveal the intracellular localization of the pathogen. Most mycobacteria had a typical rod-shaped morphology.

[Tropical malaria with a fatal outcome]. / Tropicheskaya malyariya s letal'nym iskhodom.

Tropical malaria is an acute infectious disease from a group of parasitic diseases transmitted by the vector-borne route. Russia registers deaths due to imported malaria. The paper gives brief information on the epidemiology, etiology, and clinical manifestations of the disease and describes the fatal outcome of cerebral tropical malaria, as well as morphological changes in organs and tissues. The K76T mutation associated with drug resistance in parasites was identified in the structure of the plasmodium gene.

[Ambulatory anesthesia in surgical practice in children].

A brief historical overview of the stages of development of outpatient surgery and anesthesiology is provided. It displays features of pre-selection and evaluation of patients for pediatric ambulatory surgery, the relation to the problems of preoperative fasting, anesthesia with concomitant diseases, the relative and absolute contraindications to outpatient surgeries in children. The research discusses the need and form of administration of sedative drugs in premedication in children of different ages, their influence on the recovery time after anesthesia. Compares methods of induction and maintenance of anesthesia, the possible use of volatile and intravenous anesthetics in ambulatory surgery in children, the advantages and disadvantages of given methods, as well as options for their combination with regional blocks. Pays attention to the postoperative analgesia and control of postoperative nausea and vomiting, consider their side effects.

Serum myoglobin levels in patients with ischemic myocardial insult.

Serum myoglobin levels were studied in 178 consecutive patients admitted for chest pain due to ischemic cardiac injury. Serum myoglobin level was compared with the clinical condition, electrocardiographic changes, and serum creatine kinase levels. Elevated serum myoglobin concentration was present in all patients with acute myocardial infarction, as defined by World Health Organization, Geneva, criteria, and, in addition, in about 50% of patients with so-called acute coronary insufficiency. On this basis we could define two different groups of patients with acute coronary insufficiency: cases exhibiting elevated serum myoglobin levels (group 1) and those with normal levels (group 2). In group 1 although creatine kinase levels were in the normal range, they were significantly higher than in group 2. Four patients from group 1 developed heart failure and another a typical acute myocardial infarction during hospitalization, whereas no patients of group 2 had such complications. In patients with acute myocardial infarction, the elevation of serum myoglobin preceded that of creatine kinase in most cases. Myoglobin release appears to be related to infarct size, the highest levels were found in extensive myocardial infarction and less marked elevations in cases of subendocardial infarction and in half of the cases with acute coronary insufficiency. It is proposed that serum myoglobin is a reliable measure of myocardial necrosis and serves to detect a hitherto undefined population of small-size acute myocardial infarction, with its attendant clinical and prognostic implications.

Cardiac rupture in patients with acute myocardial infarction.

The occurrence of myocardial rupture was evaluated in an unselected population of 1,737 patients with acute myocardial infarction (AMI). Patients with cardiac rupture after AMI were compared with age- and sex-matched control patients with fatal AMI not related to rupture and with AMI survivors discharged home. Rupture was found in 40 patients (15.7 percent of hospital deaths), or 2.3 percent of all cases of AMI. At the highest risk for rupture were women aged 60 to 69, although the age distribution did not differ significantly from that of patients dying of other causes. More patients with myocardial rupture had hypertension during hospitalization, persistent pain, and inferior wall myocardial infarction when compared with controls. The majority (95 percent) of cardiac ruptures occurred within the first six days, 40 percent within the first 24 hours after the onset of symptoms. Approximately 20 percent of ruptures were diagnosed as subacute; in only two was surgical intervention attempted unsuccessfully. The high-risk group of patients should be carefully monitored within the first six days after the onset of symptoms of AMI in an effort to prevent myocardial rupture.

Long-term results of coronary artery bypass surgery in patients with severely depressed left ventricular function.

STUDY OBJECTIVE: The objective of the present study was to evaluate medium- and long-term results of coronary artery bypass grafting (CABG) in patients with severe left ventricular dysfunction (LVD). DESIGN: Prospective evaluation (clinical follow-up and equilibrium radionuclide angiography scan) of all the patients with severe LVD who underwent CABG from November 1986 to November 1991 at the Tel Aviv Medical Center and were referred to the Post Cardiac Surgery Follow-up Clinic at this institution. PATIENTS: Seventy-four consecutive patients (65 men, 9 women, aged 43 to 82 years; mean age, 68.2 years) with left ventricular ejection fraction (LVEF) of 30% or less who underwent isolated CABG (without automatic implantable cardioverter-defibrillator implantation, aneurysmectomy, valve replacement, or other open heart procedures) during a 5-year period and were discharged from hospitalization were prospectively evaluated. Preoperatively, 62% of patients had angina, 65% had congestive heart failure (CHF), and the LVEF ranged from 10 to 30%. The mean number of grafts was 2.98 per patient; the internal mammary artery (IMA) was used in 54 patients. The patients were followed up 4 to 96 months (mean, 64.9 months) post-surgery for survival, clinical status, and left ventricular function. RESULTS: Survival was 96%, 93.2%, 91.9%, 87.8%, 86.5%, 83.8%, and 83.8%, at 1, 2, 3, 4, 5, 6, and 7 years, respectively. Postoperatively, mean angina class improved from 2.9 to 1.4 (p < 0.0001) and mean CHF class improved from 2.7 to 1.8 (p < 0.0001). Mean LVEF improved from 23.5% preoperatively to 35.7% postoperatively (p < 0.0001). CONCLUSIONS: The following occur in patients with coronary artery disease and severe LVD undergoing CABG: (1) good medium- and long-term survival is attained; (2) angina class improves; (3) CHF class improves; (4) LVEF objectively improves; and (5). IMA can be used safely as a conduit.

Very early onset of acute amiodarone pulmonary toxicity presenting with hemoptysis.

A case of amiodarone pulmonary toxicity (APT) occurring within days of the start of therapy and presenting with hemoptysis is reported. Both the very early onset and the presenting symptom are highly unusual in this entity. Implications in the diagnosis of APT are discussed.

Long-term follow-up after coronary artery bypass grafting reoperation.

BACKGROUND: Coronary artery bypass grafting (CABG) reoperation is being performed with increasing frequency. OBJECTIVE: To determine the clinical outcome and the long-term results of a second CABG. SETTING: An 1100-bed urban university-affiliated hospital. DESIGN: Retrieval of data on selected parameters from medical records before surgery and prospective follow-up afterwards. PATIENTS AND METHODS: We studied the outcomes of 498 consecutive patients who underwent CABG reoperation in our institution from January 1978 to December 1989 and who were followed postoperatively. Their perioperative mortality, morbidity, and long-term follow-up results were re-evaluated. The end points of the study were December 1997, 15 years of follow-up, or the patient's death. RESULTS: The perioperative mortality rate was 3%. The cumulative survival rates were 90.1%, 74%, and 63.4% at the 5-year, 10-year, and 15-year follow-ups, respectively. The cardiac event-free survival rates were 91.5%, 83.4%, and 67.8% at the 5-year, 10-year, and 15-year follow-ups, respectively. The risk factors adversely affecting long-term survival were advanced age, hypertension, and a low left ventricular ejection fraction (LVEF). CONCLUSIONS: The long-term results of cumulative survival and cardiac event-free survival in patients who underwent CABG reoperation are good. Although this reoperation is safe overall, advanced age, hypertension, and a decreased LVEF significantly increase the surgical risk.

TB or not TB: cavitary bronchiolitis obliterans organizing pneumonia mimicking pulmonary tuberculosis.

Two patients with subacute symptoms and signs compatible with pulmonary tuberculosis (TB) had right upper lobe cavitary infiltrates shown on chest radiography. In both patients, purified protein derivative and microbiologic testing excluded TB, and tissue examination yielded typical histologic changes of bronchiolitis obliterans organizing pneumonia (BOOP). Glucocorticoid therapy led to clinical and radiologic resolution. Though probably rare in this situation, BOOP should be considered in the differential diagnosis of patients presenting with clinical and radiologic features of pulmonary TB.

Impact of early exercise radionuclide cineangiography on long-term prognosis after CABG.

BACKGROUND: The immediate benefits of coronary artery bypass grafting might be only transient. This prospective study examined the capability of exercise radionuclide cineangiography done shortly after coronary artery bypass grafting to predict outcome and long-term prognosis. METHODS: Results of exercise radionuclide cineangiography at 5.5 +/- 0.7 months (range, 4 to 8 months) postoperatively were correlated with mortality, major surgical and nonsurgical cardiac events, and cardiac event-free survival in 100 consecutive patients who underwent coronary artery bypass grafting. Stepwise logistic regression analysis was used to evaluate the incremental value of radionuclide cineangiography beyond the commonly used variables. RESULTS: Left ventricular ejection fraction at rest was normal (> or = 0.45) in 72 patients and increased on exercise in 58. The exercise radionuclide variables that correlated with future cardiac events were change and fractional change in heart rate, ST segment changes, anginal pain and congestive heart symptoms during exercise, rest ejection fraction, and change and fractional changes in ejection fraction. Predictors of event-free survival were exercise heart rate, rest ejection fraction, and change and fractional change in ejection fraction during exercise. Logistic regression analysis revealed that change in ejection fraction was an independent predictor of cardiac death and surgical interventions, whereas resting ejection fraction was a predictor of nonsurgical cardiac events. CONCLUSIONS: Postoperative exercise radionuclide cineangiography carried out soon after coronary artery bypass grafting had definite independent prognostic value and should be performed routinely to help decide treatment protocol.

Plasmacytoma of the stomach.

A case of plasmacytoma of the stomach is described. The clinical presentation, diagnostic pitfalls and the treatment of this rare entity are discussed.

The influence of levodopa in the pharmacokinetics of bromocriptine in Parkinson's disease.

The administration of bromocriptine in addition to levodopa in Parkinson's disease produces beneficial results. Several hypotheses have explained the advantage of the combined treatment by a pharmacodynamic interaction in the striatum. However, no study has considered the possibility that levodopa modifies the kinetics of bromocriptine. In the present study performed with parkinsonian patients, we measured blood levels of bromocriptine (by radioimmunoassay) at 0, 30, 60, 90, 120, 180, and 240 min after the oral administration of bromocriptine alone and together with 250 mg levodopa plus 25 mg DCI. After loading of bromocriptine alone, we found mean peak levels at 60 min (1.42 ng/ml) and at 90 min (1.82 ng/ml). These values were reduced by levodopa (0.97 ng/ml at 60 min and 0.93 ng/ml at 90 min). Although we did not observe substantial clinical differences among the groups after the drug challenge (Webster scale), this study supports our previous findings and suggests that one of the advantages of a combined treatment may result from a modification of the plasma levels of bromocriptine by levodopa. A "smoothing" of the plasma bromocriptine curve possibly avoids sudden oscillations of the drug and enables a more "stable" penetrability of the medication into the central nervous system. Therefore long-term combined treatment is advised in preference to bromocriptine alone.

Dysphagia with multiple autoimmune disease.

Myasthenia gravis (MG) and polymyositis (PM) are organ-specific autoimmune diseases. Occasional reports describe patients with clinical and pathologic features of both. Achalasia is idiopathic in nature, but autoimmune and inflammatory mechanisms have been proposed for this disorder as well. We describe a patient with dysphagia who was diagnosed at different points in time with all these three rare conditions. Despite at least putatively having immune mechanisms in common, an association between the three has not been previously described.

Serum myoglobin in detection of myocardial necrosis in patients with "coronary insufficiency".

Myoglobin, an oxygen-binding protein, is synthesized exclusively in striated and cardiac muscle, and is normally found in blood. Serum myoglobin determination has been used in the diagnosis of acute myocardial infarction. Experimental work has shown that myoglobin is released only after muscular necrosis. This prospective study included 101 patients: 62 with acute coronary insufficiency, 16 with acute myocardial infarction, and 23 controls. In all the patients with infarction the serum myoglobin levels were elevated. None of the controls showed serum myoglobin above normal. In patients with coronary insufficiency the peak serum myoglobin ranged from normal to 280 ng/ml. Half of all the patients with coronary insufficiency had a significant elevation of serum myoglobin (p less than 0.001). The obvious explanation of this finding is that myocardial necrosis to some extent develops in cases of so-called coronary insufficiency. Furthermore, this study confirms previous findings that serum myoglobin assessment constitutes a very early marker of myocardial damage.

Graphic representation of sequential Bayesian analysis.

Previously undescribed algebraic transforms of Bayes' theorem define families of operating points in the receiver operating characteristic (ROC) space which, at given pre-test probability, produce constant post-test probabilities. These isopredictive operating points form straight lines in the ROC space. The lines can be used to emulate Bayesian sequential analysis in a strictly graphic procedure, which can be applied in clinical work and medical education.

Bayesian classification of vasculitis: a simulation study.

New classification criteria for vasculitic disorders have recently been proposed by the American College of Rheumatology. These classification criteria have limitations inherent to the method employed in their development. We propose a different approach to the quantitative analysis of the manifestations of vasculitis, which may improve the precision of classification criteria in this domain. Bayesian classifiers were developed for six vasculitides using literature-derived quantitative descriptions of these syndromes. These clinical data were also used in computer programs designed to generate simulations of vasculitis and control cases. The performance of Bayesian classifiers of vasculitis was then compared to that of the American College of Rheumatology criteria, using series of computer-simulated vasculitis cases. Bayesian classifiers identified simulated vasculitis cases with greater accuracy than those of the corresponding American College of Rheumatology 1990 vasculitis criteria in all six diseases studied. As predicted by theoretical considerations, Bayesian classifiers have the potential to identify vasculitis cases more accurately than the proposed American College of Rheumatology 1990 criteria.

Positive inotropic effect in the heart produced by acetylcholine.

The effect of acetylcholine on cardiac muscle contractility and hemodynamics was investigated in human atrial strips and in isolated working rat heart. Activation of the muscarinic receptor in the heart muscle is generally known to result in negative chronotropic and inotropic effects. In our study, positive inotropic effects of acetylcholine (ACh) were observed in both human right atrial strips and in the working rat heart. Exposure of the human right atrial strips to ACh (10(-7)-10(-4) M) produced a dose dependent tri-phasic (positive-negative-positive) inotropic effect in approximately 40% of the strips. In muscle strips that exhibited only a negative inotropic effect, a positive response was observed following washout of ACh. Both positive and negative effects were antagonized by atropine. Exposure of the paced working rat heart to ACh (10(-7) - 10(-5) M) resulted in a dose dependent decrease in mean coronary flow followed by depression in cardiac function. When the heart was initially treated with the vasodilator adenosine (2 x 10(-6) M), exposure to ACh (10(-7) - 10(-5) M) had no effect on coronary flow and produced a dose dependent augmentation of all cardiodynamic indices: left ventricular pressure, isovolumic pressure, cardiac output, maximal aortic flow and stroke work. This positive response was antagonized by atropine. Exposure of the rat ventricular strips increased the formation of [3H]phosphoinositide breakdown products (e.g. inositol phosphates IP, IP2, IP3). These observations demonstrate that cholinergic muscarinic stimulation may produce positive inotropic effects in both human and rat cardiac muscle. Furthermore, our results suggest that IP3 may be a mediator in this process.

[Surgical occlusion of the bronchi combined with surgery of lung abscesses or cysts in acute purulent lung diseases in children]. / Operativnaia okkliuziia bronkhov v sochetanii s pnevmoabstsessotomiei ili tsistéktomiei pri ostrykh nagnoitel'nykh zabolevaniiakh legkikh u detei.

The authors propose a new method for surgical treatment of acute purulent diseases of lungs and pleura in children consisting in a combination of operative occlusion of the bronchus of the injured portion of the lung (transection of the bronchus with suturing its ends) with pneumoabscessotomy or cystectomy. Such operations are maximum sparing, have a sufficient sanitation effect, reduce the risk of recurrence, pyopneumothorax and shorten the period of treatment.