Syncope in a 14yo female with ventricular tachycardia; an atypical etiology.

Wide complex tachycardias are rare in the pediatric population and may be due to ventricular tachycardia, aberrant conduction or antidromic tachycardia each with multiple underlying etiologies. We present a 14 yo female in extremis with syncope at rest witnessed by her mother, found in ventricular tachycardia by EMS who challenged with IVF hydration and amiodarone. Consecutive adequate fluid challenges and antiarrhythmics in the emergency department failed requiring synchronized cardioversion for stabilization. Subsequent viral panels, imaging, genetic testing and cardiac biopsy confirmed a diagnosis of arrhythmogenic right (and left) ventricular dysplasia.

Muromonab-CD3 (Orthoclone OKT3), methylprednisolone and cyclosporine for acute graft-versus-host disease prophylaxis in allogeneic bone marrow transplantation.

We report the results of a prospective non-randomized phase II study of Muromonab-CD3 (Orthoclone OKT3), an anti-CD3 monoclonal antibody, with methylprednisolone (MP) and cyclosporine (CSA) for acute GVHD (aGVHD) prophylaxis in 22 hematologic malignancy patients. OKT3 was given at 0.1 mg/kg/day with a maximum dose of 5 mg/day. Initial MP dose was 1000 mg before OKT3, with subsequent doses at 1 mg/kg/day before each OKT3 infusion with a planned taper beginning at day +28. CSA (3 mg/kg/day) was given as a continuous infusion at day -1 and adjusted to maintain serum levels between 250 and 399 ng/ml. Allogeneic BMT donors were HLA-matched siblings (n = 17), single HLA-mismatched-related (n = 1) and HLA-matched unrelated (n = 4). All patients achieved neutrophil engraftment at a median 11 days (range, 8-25 days). By intent-to-treat, the cumulative incidence of grade II-IV aGVHD was 33% (95% CI 13-53%) at a median 26 days post-BMT (range, 14-84 days). Chronic GVHD developed in 11/12 evaluable patients. Eight patients (36%) developed OKT3 first dose reactions; no cases of post-transplant lymphoproliferative disorder were observed. OKT3 depleted peripheral CD3+ cells in vivo as measured by flow cytometry. OKT3+MP+CSA combination is moderately effective aGVHD prophylaxis, however, it is unlikely to be superior to CSA+MTX.

Microalbuminuria associated with diabetic neuropathy.

OBJECTIVE: To test the hypothesis that microalbuminuria may show an independent statistical association with diabetic neuropathy. RESEARCH DESIGN AND METHODS: An observational study of a prospectively identified cohort was conducted at the University Medical Center. The cohort consisted of 78 consecutive diabetic patients who fulfilled the criteria of having diabetes for greater than 10 yr, a normal serum creatinine, urine negative for macroalbuminuria by a commonly used dipstick method, a blood glucose less than 13.8 mM (less than 250 mg/dl), and an HbA1 less than 11% (normal range 5.5-8.5%). Medical record review established the presence of chronic complications of diabetes. Urine albumin level was measured by radioimmunoassay. Albumin concn greater than or equal to 15 mg/L was used as a cutoff value for microalbuminuria. RESULTS: Twenty-five of 78 patients (32%) showed microalbuminuria. Of these, 51% had neuropathy, 39% had retinopathy, 35% arterial hypertension, 17% peripheral vascular disease, and 15% ischemic heart disease. After adjusting for age, sex, and type and duration of diabetes, diabetic neuropathy and hypertension showed a significant association with microalbuminuria. After adjusting for other diabetic complications, diabetic neuropathy showed a significant association with microalbuminuria. CONCLUSIONS: Microalbuminuria is independently associated with diabetic neuropathy. This association lends support to the theory of a vascular etiology for diabetic distal symmetrical neuropathy.

Effect of isoprenaline and nitroglycerine on pressure time indices and coronary graft blood flow in man.

In five patients studied 1 to 3 d after coronary artery surgery isoprenaline and nitroglycerine have been used to alter the systolic (TTI) and diastolic (DPTI) pressure time indices. A close correlation with the predicted relationship between diastolic coronary graft flow and the DPTI/TTI ratio has been demonstrated during isoprenaline-induced tachycardia. Nitroglycerine reduced diastolic coronary graft resistance and increased the DPTI/TTI ratio, effects which are desirable for the relief of angina.

Inotropic and vasodilator effects of amrinone on isolated human tissue.

The effects of amrinone on human umbilical artery and human myocardium were studied. Amrinone produced dose related increases in tension, dT/dtmax and dT/dtmin in myocardium from patients who were NYHA grade I (n = 1) and II (n = 4). The responses to amrinone of these tissues were similar to the response seen in normal guinea-pig myocardium (n = 34). The drug had no inotropic effect on tissue from NYHA grade III patients (n = 5). The inotropic response of the tissues to amrinone was inversely related to length of history and severity of heart failure in the patients from whom the tissues were obtained. Amrinone caused dose related relaxation of the human umbilical artery. The vasodilator properties, but not the positive inotropic effects of amrinone were detectable at concentrations of the drug obtained during oral therapy (0.4 to 4.0 micrograms X ml-1). These findings support the view that in patients with congestive cardiac failure amrinone acts by vasodilatation with no clinically important positive inotropic effect.

Total-body electrical conductivity (TOBEC): relationship to estimates of muscle mass, fat-free weight, and lean body mass.

A comparison of methods for estimating body composition (BC) of 12 subjects was made by using fat-free weight from total-body electrical conductivity (FFWT), muscle mass from 3-methylhistidine excretion (MM3MH) and creatinine excretion (MMCRE), fat-free weight from hydrostatic weighing (FFWBD), and lean body mass from whole-body potassium counting (LBMK). Data were analyzed for day-to-day variability and regression analyses were applied to compare the different methods of measuring BC. Mean values (+/- SEM, kg) for the estimates were 53.9 +/- 3.5 (FFWT), 26.9 +/- 2.9 (MM3MH), 25.3 +/- 2.5 (MMCRE), 53.2 +/- 3.6 (FFWBD), and 52.8 +/- 3.5 (LBMK). Regression analyses revealed that TOBEC estimates of fat-free weight had an adjusted r2 (+/- SEE, kg) of 0.95 +/- 2.2, 0.50 +/- 7.9, 0.95 +/- 1.8, and 0.88 +/- 4.0 for MM3MH, MMCRE, FFWBD, and LBMK, respectively. It was concluded that TOBEC is a potentially reliable method for estimating the muscle mass within the fat-free compartment, as well as fat-free weight and lean body mass.

Transendothelial chemotaxis in vitro of human monocytes.

Porcine aortic vascular endothelial cells were grown to confluence on microporous PTFE membranes and incorporated into a two-compartment chemotaxis assembly. Human peripheral blood mononuclear cells (20-25% monocytes) were placed in the upper compartment and zymosan-activated human serum (ZAHS) as chemoattractant in the lower compartment. Over a 3 h period monocytes migrated across the endothelialized membrane and adhered to a collecting filter sited in the lower compartment. Addition of ZAHS to the cell suspension in the upper compartment virtually abolished the migration response whilst only minimal leucocyte migration was supported by the bare unendothelialized PTFE membrane. The extent of transendothelial monocyte chemotaxis was dependent upon the concentration of chemoattractant in the lower compartment and upon the cell density of the suspension containing monocytes. A confluency test of fluid flow across the endothelialized filter showed that monocyte migration could take place without disturbing endothelial barrier function. The culture system is easy to assemble and the method provides experimental versatility.

Symposium on the role of the laboratory in clinical decision making--Part II. Perspectives on clinical decisions.

The critical role of expert judgment in clinical decision support has been accommodated in a class of approaches termed knowledge based systems. These have arisen from work in artificial intelligence on expert performance. Some of the perspectives and insights that have been gained from these approaches are briefly discussed.

Myocardial preservation during aortic valve surgery. Assessment of five techniques by cellular chemical and biophysical methods.

Five different types of myocardial protection were employed in this series of 168 patients undergoing aortic valve replacement. Two methods of assessing myocardial preservation were used: cellular biological estimations and quantitative polarization measurements. Both parameters showed that either of two methods, continuous perfusion at 32 degrees C. with a beating heart or cardioplegic hypothermic arrest, protected the myocardum best. Intermittent perfusion at 30 degrees C. with a fibrillating heart was the worst means of preservation. Our investigations (both clinical and experimental) have also shown that changes in birefringence, indicative of deteriorating myocardial function, are often detectable before parallel cytochemical changes are apparent.

Coumarin (1,2-benzopyrone) for the treatment of prostatic carcinoma.

The unavailability of effective treatment for metastatic hormone-refractory and clinically localized but pathologically unfavorable prostatic carcinoma warrants trial of new and promising treatments. Preliminary studies in patients with metastatic disease have shown (a) subjective but no objective responses to 100 mg coumarin and cimetidine daily; (b) objective responses in 3 of 40 patients treated with 3 g coumarin daily, all of whom had normal performance status and 1 of whom remains with three resolved bone metastases and stable prostate-specific antigen levels after 4 years; (c) toxicity only in bedridden patients. We recently initiated two multi-center trials of 1 g coumarin daily. Metastatic prostatic carcinoma patients of normal performance status were treated in a phase II trial. Patients who had been treated by radical prostatectomy, but had surgical margin, seminal vesicle or lymph node involvement or detectable prostate-specific antigen after radical prostatectomy, were randomized to coumarin or placebo.

Homemade pressure limiting vein testing device.

A device that provides a simple but effective means of controlling and accurately monitoring static distending pressures within the vein throughout testing is described.

Isolated unruptured aneurysm of the left coronary sinus of Valsalva.

An isolated unruptured aneurysm of the left coronary sinus of Valsalva was detected incidentally in a patient with a bicuspid aortic valve in whom the left circumflex coronary artery arose from the right coronary artery. With the patient on cardiopulmonary bypass, the mouth of the aneurysm was closed by suturing the reflected posterior cusp of the aortic valve to the aortic root. A Starr-Edwards prosthetic aortic valve was inserted, and an aortocoronary saphenous vein bypass graft maintained good blood flow down the left anterior descending coronary artery. Previous reports of this rare condition and its treatment are discussed.

Effects of PEEP on cardiovascular dynamics after open-heart surgery: a new postoperative monitoring technique.

The circulatory effects of incremental increases in positive end-expiratory pressure ventilation (PEEP) were assessed on 11 occasions in post-operative cardiac surgical patients by phasic aortic blood flow measurements and high-fidelity pressure recordings from which flow and pressure-flow derivatives of cardiac performance were calculated. At 15 cm H2O PEEP, mean arterial blood pressure was decreased by 10%, stroke volume and cardiac output by 15%, and peak left ventricular power by 21%. Although these indices promptly returned to control levels when PEEP was discontinued, levels of PEEP above 10 cm H2O should be used with caution for this group of patients.

A monitor for the continuous assessment of left ventricular performance after open-heart operations.

A cardiac monitoring system has been developed that incorporated phasic aortic blood flow measurement by an extractable electromagnetic flow probe and high-fidelity arterial blood pressure recordings. Cardiac output, stroke volume, and peak aortic blood flow are measured continuously; using logarithmic amplifiers, the pressure-flow derivatives of left ventricular function, such as cardiac power and stroke work, are obtained beat by beat. This monitor is used to follow the postoperative course of patients undergoing cardiac operations and to evaluate the hemodynamic effect of therapeutic agents.

Comparison of subcapsular and total orchiectomy for treatment of metastatic prostate cancer.

OBJECTIVES: To determine whether subcapsular orchiectomy provides suboptimal treatment of metastatic prostate cancer when used to avoid the psychologic consequences of the empty scrotum that results from total orchiectomy. METHODS: We compared testosterone and prostate-specific antigen levels and survival of 37 patients who underwent total orchiectomy and 37 patients who underwent subcapsular orchiectomy for metastatic prostate cancer. RESULTS: The two groups of 37 patients were similar by clinical parameters. Postoperatively, testosterone levels were 21 +/- 11 ng/dL for subcapsular versus 21 +/- 9 ng/dL for total orchiectomy patients. Tumor response was similar in the two groups when assessed by prostate-specific antigen measured 3 weeks, 6 months, and 1, 2, and 3 years postoperatively. Survival was similar when assessed using Kaplan-Meier analysis (P = 0.76). CONCLUSIONS: Subcapsular orchiectomy is a viable option for treatment of metastatic prostate cancer.

Variation in demand for accident and emergency departments in England from 1974 to 1985.

Over the period 1974-85 the range of mean annual new attendance rates at Accident and Emergency departments among English health districts was 36-673 per 1000 residents. The socio-economic diversity of these districts explained only one-third of the variation. The rates rose significantly (p less than 0.05) in 89 per cent of districts over the twelve years. Again, socio-economic variation only partly explained differences in district trends. Increases were greater among districts with higher mean rates. In order to plan first-contact care rationally we need a better understanding of the factors underlying these trends.

Effects of subsidising bus travel on the occurrence of road traffic casualties.

Between 1975 and 1 April 1986, public transport by bus in the metropolitan county of South Yorkshire, England, was increasingly subsidised. Trends in road traffic accident casualties between 1974 and 1983 in all the six provincial English metropolitan counties have been compared in order to examine the possible effect of this unique subsidy on the incidence of road traffic accident casualties. During that period the total number of casualties in South Yorkshire did not change significantly compared to the other metropolitan counties. However, the proportion of all casualties in South Yorkshire who were bus occupants did increase relative to other metropolitan counties, indicating either an increase in the amount of bus travel or a decrease in travel by other modes. There was a large increase in bus patronage in South Yorkshire relative to the other metropolitan counties, and the conclusion is that it is the transport policy in South Yorkshire which resulted in an actual increase in distances travelled by bus. Since bus is the safest form of road travel, it is concluded that the public transport subsidy in South Yorkshire has benefited the health of the local population by providing the social amenity of additional travel at the least additional health cost.

The Alcohol Problems Questionnaire: reliability and validity.

The Alcohol Problems Questionnaire (APQ) was designed as a clinical instrument for measuring alcohol-related problems. It has been used to study the relationship between alcohol-related problems and dependence within the bi-axial model. The reliability of the APQ was, however, unknown. In the present study 101 subjects participated in a test-retest reliability study. Dependence and consumption scores were obtained along with socio-demographic information in order to study the construct validity of the APQ. The APQ was found to be highly reliable and the previous finding that dependence is a mediating factor in the relationship between consumption and problems was replicated. These findings add further weight to the view that alcohol-related problems represent a phenomenon which is conceptually, as well as statistically, distinct from dependence. Further, the APQ is reliable, simple to administer and is likely to be useful in the assessment and study of problem drinkers in the clinical and research settings.

The lifespan personal health record.

A system for entry of health data in a computer-based patient record by lay individuals is described. The lay user is supported in data entry and data clarification, as well as by system-supported summarization of the data in context to show relationships, highlight sentinel events, and assist in evaluation of alternative decisions and actions as needed.

The left ventricular resectoscope. A new instrument for the comprehensive resection of the left ventricular outflow tract in hypertrophic obstructive cardiomyopathy (HCOM).

After disappointing results with non-surgical measures there is now a move back towards surgical left ventricular outflow tract resection as a treatment of choice for hypertrophic obstructive cardiomyopathy. The traditional operation presents various technical difficulties and occasionally disappointing results. Using a diathermy loop to resect the hypertrophied outflow tract has provided a much more convenient and reliable technique. This paper describes an instrument incorporating all the features of this technique (Left ventricular resectoscope).