Improved technique of intraaortic balloon insertion.

Routine insertion of an intraaortic balloon through the femoral artery may be difficult in the face of obstructive aortoiliac atherosclerosis. Perioperatively, the balloon catheter may be guided through diseased vessels by transabdominal palpation.

Postprandial effect of a high fat meal on plasma lipid, lipoprotein cholesterol and apolipoprotein measurements.

We investigated the effect of a fatty meal on plasma concentrations of lipids, apolipoproteins, and the cholesterol component of lipoproteins. Sixteen nonobese, healthy, asymptomatic males, 22-34 years of age, served as subjects for this study. None smoked, consumed more than two alcoholic drinks per day, or took any medication known to alter plasma lipids. After a 12 h fast, baseline plasma samples were obtained just before subjects consumed a high fat meal. The meal, standardized to a 70 kg individual, contained approximately 70 g fat, 580 mg cholesterol, and 1,100 cal, with 56% of the calories coming from fat. During the 8 h following consumption of the meal, subjects rested quietly and consumed no food or beverages except water. Blood specimens were obtained hourly. There was a significant increase in plasma triglyceride (150% from baseline at 3 h, P less than 0.0005). Very low density lipoprotein cholesterol (VLDL-C) concentrations increased 150% at 3 h (P less than 0.0005) while low density lipoprotein cholesterol (LDL-C) concentration decreased 37% at 3 h (P less than 0.005) when estimated by Friedewald's formula. No statistically significant differences were observed between fasting total cholesterol, high density lipoprotein cholesterol (HDL-C). HDL2-C, and HDL3-C, apolipoprotein AI (apo AI, AII), and B-100 concentrations and non-fasting samples. We conclude that plasma triglyceride concentration is significantly affected in the post-prandial state. As a result, VLDL-C and LDL-C when assessed by the Friedewald formula are also altered. A minimum of 8 h fasting is required to assess these concentrations accurately in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimal trauma cholecystectomy (a "no-touch" procedure in a "well").

Salient features of an operative technique designed to reduce to a minimum the iatrogenic trauma of cholecystectomy include a limited incision, muscle retraction (instead of division), specific packing and retraction, and distant manipulations by long instruments. Eighty two unselected consecutive patients with primary gallbladder disease underwent operation by this technique. Two permanently bed-confined patients were excluded from study. Acute cholecystitis was documented by histopathology review in 23 cases and chronic cholecystitis in 57 cases. Case material included usual pre-existing concomitant medical problems; five patients meeting formal criteria for the diagnosis of morbid obesity; 15 patients exceeding 199 pounds and one weighing 315 pounds; ambulatory (outpatient) cholecystectomy; 17 patients over 70 and four patients over 80 years of age; five gangrenous and one perforated gallbladders, and perigallbladder abscesses without gangrene in one case; and conspicuous absence of respiratory complications. Median and average incision length was 5.5 cm. There were no major and five minor complications. Recent experience demonstrated safe performance of elective cholecystectomy for chronic disease, regardless of degree of patient obesity, with median incision length 5 cm, median operative time 65 minutes and median post-operative hospital stay 2 days.

The Letton-Q modified Roux-en-Y.

Roux-en-Y enteric diversion is useful for correction of alkaline reflux gastritis consequent to loop gastro-enterostomy, in the treatment of spontaneous enterogastric reflux and esophagitis, and in the configuration of primary peptic ulcer surgery. Construction of the Roux-en-Y, however, may be technically difficult or hazardous and is time consuming. Conversion of a loop gastroenterostomy into Roux-en-Y topology by umbilical tape ligation of the afferent limb and jejunojejunostomy was reported by A. Hamblin Letton in 1978. With the availability of stapling devices, the Letton procedure acquires new significance as an attractive alternative to the classic Roux-en-Y.

Pediatric annular pancreas: twenty years' experience.

Characterization of pediatric annular pancreas is provided by this analysis of 24 cases (22 neonates, 1 infant, 1 child). Salient observations include: (1) Presentation is affected by the degree of duodenal obstruction at birth and by coexistent anomalies. (2) Polyhydramnios usually accompanies complete high intestinal obstruction by annular pancreas. (3) Primary biliary interruption was not encountered and jaundice was not unusually prevalent. (4) There is a high incidence of associated anomalies. (5) Duodenal bypass by duodenoenterostomy was employed with excellent results.

Snore-induced Mallory-Weiss syndrome.

A Mallory-Weiss gastric mucosa laceration and upper gastrointestinal bleed was caused by intense snoring. This cause of gastrointestinal hemorrhage should be considered in the patient who snores.

Fistulation to the pancreatic duct complicating duodenal peptic ulcer.

A previously unreported complication of peptic ulcer disease is described--fistula formation between the duodenum and the pancreatic duct. Symptoms that initially were typical for ulcer disease changed abruptly in intensity, character, and timing when fistulation occurred. Diagnosis of this complication was elusive. Symptoms resolved completely after alimentary diversion by a Billroth II hemigastrectomy combined with truncal vagectomy.

Operative cholangiography by direct puncture of the common bile duct.

Direct common bile duct puncture offers an alternative to cystic duct cannulation in performance of operative cholangiography. Materials are readily available; no unusual cannulas or clamps are needed. The technique is easily mastered and consistently successful. Multiple roentgenograms, including one obtained after aspiration of dye from the duct, are of great advantage in detecting small stones. Careful application of puncture of the common bile duct does not add to morbidity nor does it prolong the recovery period.

The dog heartworm (Dirofilaria immitis) in man. An epidemic pending or in progress?

Human infection with the dog heartworm (Dirofilaria immitis) may lead to focal pulmonary infarction with granuloma formation. The resulting roentgenographic coin lesion may require a diagnostic thoracotomy in consideration of malignancy. Because of sometimes enigmatic histopathological characteristics, this process may not be receiving the recognition it deserves. Furthermore, the dramatic increase of primary (canine) host infections in the United States presages an increase of secondary (human) host infections. Many thoracotomies will be performed for this innocuous process unless the dirofilarial agent can be controlled or the human pulmonary lesion can be reliably identified without operation.

Small bowel perforation secondary to metastatic carcinoma of the lung.

This is a report of small bowel perforation secondary to a metastasis from a primary adenocarcinoma of lung in a 62-year-old woman five months after resection of the primary tumor. She had received radiation therapy and corticosteroids after surgery. Features of this and five previously reported cases are discussed. Modern therapy may alter the course of pulmonary cancer resulting in more frequent observation of this rare complication.

Structural determination and promoter analysis of the chicken mitogen-inducible prostaglandin G/H synthase gene and genetic mapping of the murine homolog.

We have previously reported the isolation and characterization of a new form (PGHS-2) of prostaglandin G/H synthase (PGHS, cyclooxygenase) from chicken embryo fibroblasts. To further study the regulation and structure of the gene, we have cloned the entire chicken PGHS-2 (previously termed miPGHSch) gene with its 5'-flanking region from a chicken genomic library. A genomic Southern blot showed the existence of a single PGHS-2 gene. The size of the gene was estimated at 8.9 kb through DNA sequencing and polymerase chain reaction analysis. The PGHS-2 gene was found to contain 10 exons, giving it a structure similar to that of the human PGHS-1 and murine PGHS-2 genes. The transcription start site was determined by primer extension, and the nucleotide sequence of 1.6 kb of the 5'-flanking region immediately upstream of the transcription start site was determined. The promoter sequence contained a TATA box and a variety of enhancer elements, including a serum response element, an AP-1, an NF-kappa B, and several SP-1 and AP-2 sites. Chloramphenicol acetyltransferase (CAT) assays showed that the first 158 nucleotides of the promoter efficiently drove transcription of the CAT reporter gene in serum-stimulated cells. Dexamethasone, a potent inhibitor of prostaglandin synthesis, had no effect on CAT activity, although this drug is known to markedly decrease PGHS-2 mRNA in vivo. This suggests that dexamethasone may inhibit PGHS-2 mRNA expression at the post-transcriptional level. Analysis of hamster/mouse somatic cell hybrids with radiolabeled cDNA probes demonstrated that PGHS-1 mapped to chromosome 2 and PGHS-2 mapped to chromosome 1 of the mouse genome.

Hyperlipemic response of young trained and untrained men after a high fat meal.

To test the hypothesis that endurance training is associated with a decreased lipemia after a high fat meal, 16 young men [22 to 34 years old, nine of whom were trained (T) and seven of whom were untrained (UT)] were recruited. T ran greater than 30 or biked greater than 100 miles a week, while UT had been sedentary for at least the preceding 3 months. Daily caloric intake and daily caloric expenditure during exercise were 35% and 704% greater, respectively, in T than in UT. VO2max was 31% greater, while percent body fat was 36% lower in T than in UT. Dietary composition and body height and weight were similar. After a fasting blood sample was taken, the men ate a high fat meal (approximately 56% of total calories as fat in 1100 kcal adjusted to body weight), and additional blood samples were taken hourly for 8 hours. Fasting lipids were similar. Postprandial peak triglyceride (TGmax), percent TG increase (%TGI), and total lipemic response (TLR, the area under the lipemia curve in excess of fasting TG) were 42%, 54%, and 75% greater, respectively, in UT vs. T. Stepwise regression analysis showed that the same three-variable model (training status, fasting TG, and VO2max) described the variation in TGmax (R2 = 0.97), %TGI (R2 = 0.75), and TLR (R2 = 0.92). Furthermore, this same analysis showed that after adjustment for fasting TG and VO2max, the UT group had a significantly greater postprandial lipemia whether expressed as TGmax (p less than 0.0001), %TGI (p = 0.0002), or TLR (p = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic biotransformation in rodents and physicochemical properties of 23(R)-hydroxychenodeoxycholic acid, a natural alpha-hydroxy bile acid.

The hepatic biotransformation in the rat and hamster of 23(R)-hydroxychenodeoxycholic acid (23(R)OH-CDCA), the alpha-hydroxy derivative of CDCA, was defined; some physiological and physicochemical properties were also assessed. 23(R)OH-CDCA was isolated from duck bile; [24-14C]23(R)OH-CDCA was synthesized. The compound was administered intravenously to anesthetized biliary fistula rats at doses of 1, 3, or 5 mu mol/kg-min and to hamsters at 3 mu mol/min-kg. Biliary bile acids and radioactivity were analyzed by thin-layer chromatography (TLC), high pressure liquid chromatography (HPLC), and gas chromatography-mass spectrometry (GC-MS). Recovery of radioactivity in bile was incomplete (50-70% of infused dose); some was also recovered as breath 14CO2. Radioactivity in bile was present as unchanged compound (25-50%, dose-dependent) and its conjugates (with taurine, with glycine, or with glucuronate). Nor-CDCA (C23) was present in bile (in both unconjugated and conjugated form), indicating that 23(R)OH-CDCA had undergone oxidative decarboxylation (alpha-oxidation) with loss of the C-24 carboxyl group. The alpha-oxidation was 20 +/- 5% (mean +/- SD) of administered dose in the rat and was not dose-dependent; in hamsters, alpha-oxidation was 35 +/- 8%. In rats, the S isomer of 23OH-CDCA also underwent alpha-oxidation (10 +/- 2%). Nor-CDCA also underwent 6beta-hydroxylation to form nor-alpha-muricholic acid, as well as reduction of its C-23 carboxyl group to form the C23 alcohol. The taurine conjugate of 23(R)OH-CDCA [23(R)OH-CDC-tau] was prepared synthetically and characterized by 1H-NMR. By surface tension measurements, it had a critical micellization concentration (CMC) of 3.5 mM (in 0.15 M Na+), as compared to 1.8 mM for CDC-taurine. Aqueous solubility of 23(R)OH-CDCA increased markedly above pH 5, compared to pH 7 for CDCA. When incubated with cholylglycine hydrolase, 23(R)OH-CDC-tau was deconjugated at a rate one-fourth that of CDC-tau. It is concluded that the presence of a 23(R)-hydroxyl group in a 3alpha, 7alpha-dihydroxy bile acid alters its metabolism in the rodent hepatocyte, as evidenced by inefficient conjugation with taurine or glycine, alpha-oxidation to nor (C23) bile acid, and reduction of the nor bile acid to the primary alcohol. The taurine conjugate of 23(R)OH-CDCA, a major biliary bile acid of marine mammals and wading birds, is a biological detergent with properties superior to those of the taurine conjugate of CDCA. Natural C23 nor-bile acids may be formed by alpha-oxidation of alpha-hydroxy C24 bile acids.