Traditional herbal remedies that influence cell adhesion molecule activity.

Many traditional medicines have demonstrated immune activity, however, research has largely neglected their effects on cell adhesion molecules (CAMs). This review reports on extracts from 37 medicinal plant species, similar to or replicating traditional preparations, that up- or downregulate either gene or protein activity of CAMs. The majority of the investigations were in vitro, primarily of the immunoglobulin superfamily of CAMs, specifically intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) and secondarily on the integrin (CD11b or MAC-1) and selectin (E-selectin and P-selectin) families of CAMs. The following plant species have demonstrated modulation of multiple CAMs: Artemisia asiatica, Boswellia serrata, Canscora decussata, Cinnamomum povectum, Dehaasia incrassate, Ganoderma lucidum, Ginkgo biloba, Hypericum perforatum, Juglans regia, Lycopus lucidus, Panax notoginseng, Rheum undulatum, Salvia miltiorrhiza. Many other species have documented activity on one CAM. Currently there are limited in vivo/ex vivo investigations, including a clinical trial on Mahonia aquifolium. Although further evidence is needed, the data suggest that the reviewed botanical medicines may have the potential to provide therapeutic potential in disease processes involving CAMs. Additionally, the reported success of many of these plant extracts by traditional cultures and modern phytotherapists may involve the modulation of CAMs.

Conservative management of uremic pericardial effusions.

Although there has been a recent trend toward early operative treatment of uremic pericardial effusions unresponsive to intensified dialysis, this approach may be unnecessarily aggressive. Review of 787 patients in our chronic dialysis program since 1969 has shown 54 patients (6.9 percent) to have developed 56 episodes of large pericardial effusion. All were managed by increasing the frequency of dialysis. If the effusion failed to diminish or if life-threatening signs of tamponade developed, pericardiocentesis was performed. In 63 percent (35/56) the effusion resolved with increased dialysis. In 37 percent (21/56), pericardiocentesis was performed, with 57 percent (12/21) requiring only one aspiration. During a mean follow-up of 34 months (2 to 100 months) only 5.5 percent (3/54) have undergone operation: one partial pericardiectomy incidental to pulmonary decortication and two pericardiectomies for late (3 months and 5 months, respectively) constriction. There were five complications of pericardiocentesis: one pneumothorax, one pneumoperitoneum, one costochondritis, and two myocardial punctures without sequelae. The one death related to pericardial effusion in this series occurred in a home-dialysis patient who arrived in the emergency room moribund. Our experience suggests that the great majority of uremic pericardial effusions can be effectively controlled with simple needle aspiration by experienced personnel and that pericardial resection is usually not necessary.

Comparative results of angioplasty and aortofemoral bypass in patients with symptomatic iliac disease.

Advantages and limitations of percutaneous transluminal angioplasty (PTA) and aortofemoral bypass (AFB) performed for the treatment of iliac atherosclerosis were retrospectively studied in 61 patients who presented over a four-year period. Technical success was achieved in 92% and symptoms initially relieved in 80% of 25 patients who underwent 31 PTA procedures for iliac stenosis or occlusion. Similarly, 92% (33/36) of patients treated with AFP improved clinically. There were no operative deaths in either group or significant difference in the rate of major complications. During the follow-up period, symptoms recurred in nine PTA patients (36%) due to progressive (five patients) or recurrent (four patients) disease within the iliac vessels. Late failure of AFB (8%) was significantly less frequent. While both PTA and AFB provide satisfactory initial relief of ischemic symptoms due to iliac atherosclerosis, long-term results of PTA are limited by progressive or recurrent disease in the iliac vessels.

Routine fiberoptic endoscopic evaluation of swallowing following prolonged intubation: implications for management.

HYPOTHESIS: Fiberoptic endoscopic evaluation of swallowing (FEES) will identify patients who are at high risk for pulmonary aspiration due to swallowing dysfunction after prolonged intubation. Based on the results of FEES, dietary recommendations can be made to decrease the incidence of aspiration after prolonged intubation. DESIGN: Patients who were intubated for at least 48 hours were evaluated for swallowing dysfunction by bedside FEES within 48 hours of extubation. Differences in potential risk factors between aspirators and nonaspirators were analyzed. Dietary recommendations were made and patients were followed up for signs of clinically significant aspiration. SETTING: Community teaching hospital. PATIENTS: Fifty-one consecutive patients with no previously documented swallowing disorder who required a minimum of 48 hours of intubation for mechanical ventilation. INTERVENTIONS: Fiberoptic endoscopic evaluation of swallowing was performed by a speech pathologist. Initial diet orders were determined by results of the swallowing study. MAIN OUTCOME MEASURES: Incidence of swallowing dysfunction following prolonged intubation and incidence of clinically significant aspiration following initiation of oral feeding. RESULTS: Incidence of swallowing dysfunction was 56% (27/48); 12 (25%) of 48 patients were silent aspirators. In comparing aspirators with nonaspirators, no significant differences in potential risk factors or comorbidities were seen. Nineteen (70%) of the 27 patients aspirated with thin-consistency test liquids, and the other 8 (30%) with puree consistency. No patients in this study group developed a clinically significant aspiration following initiation of appropriately modified diets. CONCLUSIONS: Fiberoptic endoscopic evaluation of swallowing identified swallowing dysfunction in more than 50% of patients intubated for longer than 48 hours, many of whom are silent aspirators. Dietary recommendations based on FEES results prevented clinically significant aspiration.

Combined preoperative radiation and mitomycin/5-fluorouracil treatment for locally advanced rectal adenocarcinoma.

BACKGROUND: In the treatment of locally advanced rectal carcinoma, radiation therapy before surgery has been shown to decrease local recurrence rates, but has minimal effect on survival. Recently, chemotherapy in combination with preoperative radiation therapy has been shown to be effective for certain malignancies. We postulated that such combination therapy might improve the resectability of advanced rectal cancer. STUDY DESIGN: During a 4-year period we treated 20 patients with locally advanced adenocarcinoma of the rectum using a protocol of preoperative simultaneous pelvic irradiation (4,030-6,040 cGy) and infusion chemotherapy (5-fluorouracil 100 mg/m2 per day over 96 hours and mitomycin 10 mg/m2) followed by surgical resection. Effects of therapy on resectability, tumor size, recurrence and survival, and complications of treatment were evaluated. RESULTS: Minimal toxicity was observed and all patients completed their scheduled preoperative therapy. Reduction in tumor size after chemoradiation, as measured by CT scan, averaged 61% (range 20-100%). Twenty percent had a complete pathologic response to preoperative therapy, with no tumor found in the surgical specimen. Using Kaplan-Meier survival curves, the 5-year survival was estimated to be 64+/-11%, and cancer free and local pelvic control rates were 41+/-12% and 88+/-8% respectively. CONCLUSIONS: We believe that preoperative combination radiation and chemotherapy may provide significant benefit for patients with locally advanced rectal cancer, and that further, large scale studies of this treatment regimen are warranted.

An improved system for surgical excision of needle-localized nonpalpable breast lesions.

A technique for improved localization and surgical excision of nonpalpable breast lesions is described. The method employs an atraumatic outer stiffening cannula which is available in a variety of lengths and eliminates several of the technical difficulties encountered during these procedures. Successful initial excision of over 50 consecutive nonpalpable breast lesions has been obtained with this technique.

Limb salvage in diabetics: challenges and solutions.

Our current understanding of wound healing in the diabetic suggests that proper management of the blood glucose level is a necessary but not sufficient condition for containment of infection and optimal wound healing. The pathologic changes observed in the peripheral capillary bed of diabetics are somewhat variable and have no consistent relationship to the wound healing process. Occlusive disease of the arterioles is probably quite similar in significance and distribution to normoglycemic patients with peripheral vascular disease and suggests that proximal arterial occlusion is the major determinant of poor distal perfusion. These observations offer strong evidence that sufficient runoff vessels are present to support attempts at reconstruction of obstructing lesions of the aortoiliac and infrainguinal arterial segments. Noninvasive vascular laboratory data and arteriograms must be carefully interpreted in order to assess fully the degree of arterial occlusive disease that exists as well as the potential for vascular reconstruction. Clinical experience is especially helpful in proper patient selection. Aggressive attempts at distal revascularization can achieve functional limb salvage in the great majority of patients, provided that meticulous technical standards are observed. Conservative surgical debridement and minor amputations are often successful in managing problems of soft-tissue necrosis once pulsatile flow has been restored.

Methods for the metabolic quantification of regional myocardial ischemia.

An adequate balance between oxygen supply and demand is a basic requirement for normal cardiac function. When oxygen supply does not meet the demand, progressive cellular damage occurs leading to cardiac dysfunction and, ultimately, tissue death. While traditionally "ischemia" has been defined as decreased oxygen supply secondary to a decrease in blood flow, and "hypoxia" as decreased oxygen supply secondary to a decrease in oxygen tension, this review defines ischemia in its broader sense, namely as a pathophysiologic state in which there is a lack of oxygen relative to the demand for it. In a large number of experimental studies involving the heart, there is need to promptly recognize the ischemic state, to monitor its course in vivo, and to quantify it. Because of cardiac autoregulatory mechanisms, research methods which attempt to quantify supply (e.g., measurement of myocardial blood flow) and/or demand (e.g., measurement of myocardial oxygen consumption) do not necessarily reflect the status of the balance between supply and demand. An imbalance between myocardial supply and demand is more likely to be reflected by metabolic fluxes and by the accumulation of products specific to the ischemic state. Thus, the purpose of this review is to summarize the various methods available to the cardiac surgical investigator today for the metabolic quantification of myocardial ischemia. Due to the complexity of the heart and its inherent regional differences, myocardial ischemic changes are frequently regional in nature. Thus, this review will address metabolic methods for the regional quantification of myocardial ischemia.

Neuromuscular and vascular hamartoma of the small bowel.

Neurovascular and muscular hamartoma is an unusual benign neoplasma of the small intestine. The clinical and pathological features of this lesion, which we recently encountered in a 91-year-old male, are the subject of this report and are discussed in the context of previously described cases.

Hemodynamic and metabolic responses to graded microvascular occlusion.

The hemodynamic and metabolic consequences of microvascular occlusion, often present in the runoff bed of distal arterial reconstructions, have been difficult to quantitate clinically. To investigate these pathophysiologic relationships, a porcine hindlimb model was developed in which arteriolar patency, which we term outflow capacity, may be quantitatively defined and reduced by serial distal microembolization with 70 microns flow-directed glass bubbles. In 10 anesthetized adult pigs, hindlimb perfusion was limited to femoral artery flow (FAF) by collateral ligation. Serial measurements of outflow resistance (OR), femoral artery flow, and resting muscle pH (mpH), a metabolic index of tissue perfusion, were made as relative outflow capacity (ROC) underwent graded reduction from 1.0 (baseline) to 0 (complete occlusion). Femoral artery flow decreased linearly (FAF = 87 ROC - 3), and outflow resistance increased in hyperbolic fashion (OR = 1.66/ROC) in response to graded peripheral microembolization, whereas resting muscle pH followed a more complex relationship (In mpH = 0.055 ROC + 1.95). An integrated analysis of these results suggests that a 50% to 60% reduction in arteriolar patency represents a critical point beyond which outflow resistance rises rapidly and hindlimb flow decreases to levels that are inadequate to support the metabolic demands of resting tissues.