Red blood cell transfusion practices in very low birth weight infants in 1990s postsurfactant era.

The purposes of this study are (1) to evaluate the practice of red blood cell transfusions in very low birth weight (VLBW) infants (between 501 to 1500 g) during the postsurfactant era of the 1990s; and (2) to evaluate if there is a decreasing trend in red cell transfusions in the 1990s. Database and medical records of VLBW infants admitted to the neonatal intensive care unit (NICU) between January 1990 and December 1995 at Scott & White Clinic, Temple, Texas, were reviewed. Five hundred twenty-seven infants were admitted to the NICU, excluding 5 infants that were transferred out for possible cardiac surgery or for other reasons. Fifty one (9.7%) of these infants died prior to discharge. Hence, data from 476 survivors were reviewed for red blood cell (RBC) transfusions. Transfusions were given at the discretion of the attending neonatologist. None of the infants received erythropoietin. Of the 476 infants, 289 (61%) received RBC transfusions during the hospital stay, with 2.7+/-3.6 transfusions per infant with a volume of 40.5+/-50.4 mL/kg. Smaller infants required significantly more transfusions compared to larger infants when divided into 250-g subgroups. No statistically significant difference was noted in the number of RBC transfusions per infant or number of infants transfused during the 6-year period from year to year. We conclude that VLBW infants in the 1990s postsurfactant era required 2.7 RBC transfusions per infant, on average, with the smallest infants requiring the most transfusions. These data will be helpful to counsel mothers in preterm labor regarding the need of transfusions for each birth weight category. Red cell transfusion practice has not changed over this 6-year period in the 1990s. Additional measures such as erythropoietin or even stricter transfusion criteria may be necessary to decrease transfusions further. However, safety of such measures should be carefully evaluated.

Differential transesophageal echocardiographic diagnosis between linear artifacts and intraluminal flap of aortic dissection or disruption.

BACKGROUND: The relatively low specificity of transesophageal echocardiography (TEE) for the diagnosis of aortic dissection (AD) or traumatic disruption of the aorta (TDA) has been attributed to linear artifacts. We sought to determine the incidence of intra-aortic linear artifacts in a cohort of patients with suspected AD or TDA, to establish the differential TEE diagnostic criteria between these artifacts and true aortic flaps, and to evaluate their impact on TEE diagnostic accuracy. METHODS AND RESULTS: During an 8-year period, patients at high risk of AD (n = 261) or TDA (n = 90) who underwent a TEE study and had confirmed final diagnoses were studied. In an initial retrospective series, linear artifacts were observed within the ascending and descending aorta in 59 of 230 patients (26%) and 17 of 230 patients (7%), respectively. TEE findings associated with linear artifacts in the ascending aorta were as follows: displacement parallel to aortic walls; similar blood flow velocities on both sides; angle with the aortic wall > 85 degrees; and thickness > 2.5 mm. Diagnostic criteria of reverberant images in the descending aorta were as follows: displacement parallel to aortic walls, overimposition of blood flow, and similar blood flow velocities on both sides of the image. In a subsequent prospective series (n = 121), systematic use of these diagnostic criteria resulted in improved TEE specificity for the identification of true intra-aortic flaps. CONCLUSIONS: Misleading intra-aortic linear artifacts are frequently observed in patients undergoing a TEE study for suspected AD or TDA. Routine use of the herein-proposed diagnostic criteria promises to further improve TEE diagnostic accuracy in the setting of severely ill patients with potential need for prompt surgery.

Genetic relationship between cyclic ovarian activity in heifers and cows and beef traits in males.

Records were collected in an experimental herd over an 11-year period from purebred Charolais heifers (n=351), cows (n=615) and young entire bulls (n=383). The objective of the study was to estimate the genetic relationship between the components of female ovarian activity (age at puberty and postpartum anoestrus length), their growth rate and body condition score and beef traits measured on related bulls. Two methods were used to estimate age at puberty and postpartum anoestrus length: the detection of oestrous behaviour and a test of cyclicity based on plasmatic progesterone assay. This study shows the existence of significant heritability estimates for the different cyclicity traits (h(2) between 0.11 and 0.38). Most of the genetic correlation coefficients between ovarian activity and growth rate of females and males are negative and favourable (r(g) between - 0.43 and 0.06). Cyclicity is also favourably related with body condition score in young or adult females (r(g) between - 0.65 and - 0.22). The genetic relationship between female ovarian activity and proportion of adipose tissue in the male carcass is, however, close to zero. These results show that an antagonism between male beef traits measured in this study and female ovarian activity is unlikely to be a cause for concern in the short term.

Grading of tumors and tumorlike lesions of bone: evaluation by FDG PET.

UNLABELLED: Clinical diagnosis of skeletal tumors can be difficult, because such lesions compose a large, heterogeneous group of entities with different biologic behaviors. The aim of this prospective study was to assess the value of PET in grading tumors and tumorlike lesions of bone. METHODS: Two hundred two patients with suspected primary bone tumors were investigated using FDG PET. Uptake of FDG was evaluated semiquantitatively by determining the tumor-to-background ratio (T/B). All patients underwent biopsy, resulting in the histologic detection of 70 high-grade sarcomas, 21 low-grade sarcomas, 40 benign tumors, 47 tumorlike lesions, 6 osseous lymphomas, 6 plasmacytomas, and 12 metastases of an unknown primary tumor. RESULTS: All lesions, with the exception of 3 benign tumors, were detected by increased FDG uptake. Although sarcomas showed significantly higher T/Bs than did latent or active benign lesions (P < 0.001), aggressive benign lesions could not be distinguished from sarcomas. Using a T/B cutoff level for malignancy of 3.0, the sensitivity of FDG PET was 93.0%, the specificity was 66.7%, and the accuracy was 81.7%. CONCLUSION: FDG PET provides a promising tool for estimating the biologic activity of skeletal lesions, implicating consequences for the choice of surgical strategy.

[Hyperbaric oxygen therapy in retinal artery occlusion]. / Hyperbare Sauerstofftherapie bei arteriellen Gefässverschlüssen der Netzhaut.

UNLABELLED: Retinal artery occlusion (RAO) is an ophthalmological emergency that causes a major decrease of visual parameters in most of the cases. Purpose of this pilot study was to evaluate the effect of adjunctive hyperbaric oxygen therapy (HBO) on visual acuity (VA). PATIENTS AND METHODS: Patients with acute central or branch artery occlusion (CRAO/BRAO) consecutively admitted to our hospital were offered adjunctive HBO. Standard therapy consisted of ocular massage for 3 minutes, paracentesis and intravenous acetazolamide. HBO (3 x 30 minutes at 240 kPa) was applied t.i.d. on the first day, b.i.d. on day 2 and 3 and o.d. for at least another 4 days. Patients who refused HBO or had contraindications served as controls. VA was measured according to the guidelines of ETDRS. The follow up was 3 months. RESULTS: HBO: 8 patients with CRAO showed a mean increase in VA of 1 line, 4 of 8 patients had an increase of 2 lines and more, in 3 of 8 patients VA was unchanged and one patient suffered a decrease of 6 lines. 10 patients with BRAO showed a mean increase in VA of 8 lines, 8 of 10 patients showed an mean increase of 2 and more lines, in 2 of 10 patients VA was unchanged. CONTROLS: 8 Patients with CRAO had a mean increase of 2 lines during follow up, 3 of 8 patients showed an increase of 2 lines and more, in 5 of 8 patients VA was unchanged. 6 patients with BRAO had a mean increase of VA of 4 lines, 3 of 6 patients had an increase of 2 lines and more, one patient lost 3 lines and in 2 patients VA was unchanged. The results are compared to the literature. CONCLUSIONS: HBO seems to be beneficial for VA in eyes with BRAO. Further investigations are necessary to prove this observation.

Genetic variability of the length of postpartum anoestrus in Charolais cows and its relationship with age at puberty.

Fertility records (n = 1,802) were collected from 615 Charolais primiparous and multiparous cows managed in an experimental herd over an 11-year period. The objectives of the study were to describe the genetic variability of the re-establishment of postpartum reproductive activity and the relationship with body weight (BW) and body condition score (BCS) at calving and age at puberty. The length of postpartum anoestrus was estimated based on weekly blood progesterone assays and on twice daily detection of oestrus behaviour. The first oestrus behaviour was observed 69 days (+/-25 days s.d.) post-calving and the first positive progesterone measurement (>or=1ng x ml(-1)) was observed at 66 days (+/-22 days s.d.) for the group of easy-calving multiparous suckling cows. Estimates of heritability and repeatability were h2 = 0.12 and r = 0.38 respectively, for the interval from calving to first oestrus (ICO). Corresponding values were h2 = 0.35 and r = 0.60 for the interval from calving to the first positive progesterone test (ICP). The genetic correlation between both criteria was high (rg = 0.98). The genetic relationships between postpartum intervals and BW and BCS of the female at calving were negative: the genetic aptitude to be heavier at calving and to have high body reserves was related to shorter postpartum intervals. A favourable genetic correlation between age at puberty and postpartum intervals was found (rg between 0.45 and 0.70). The heifers which were genetically younger at puberty also had shorter postpartum intervals.

Evaluation of neoadjuvant therapy response of osteogenic sarcoma using FDG PET.

UNLABELLED: According to the current treatment protocol of the Cooperative Osteosarcoma Study (COSS), monitoring preoperative chemotherapy response and estimating grade of tumor regression in patients with osteosarcoma is mandatory before surgical removal of the tumor, particularly if a limb salvage procedure is intended. In addition, response to neoadjuvant chemotherapy is considered as an important prognostic indicator. The aim of this prospective study was to assess the usefulness of 2-(18F) fluoro-2-deoxy-D-glucose (FDG) PET in the noninvasive evaluation of neoadjuvant chemotherapy response in osteosarcoma. METHODS: In 27 patients with osteosarcoma, we determined tumor-to-background ratios (TBRs) of FDG uptake with PET, before and after neoadjuvant chemotherapy according to COSS 86c or COSS 96 protocols, respectively. We compared changes in glucose metabolism of osteosarcomas with the histologic grade of regression in the resected specimen, according to Salzer-Kuntschik, discriminating responders (grades I-III; n = 17) and nonresponders (grades IV-VI; n = 10). RESULTS: The decrease of FDG uptake in osteosarcomas expressed as a ratio of posttherapeutic and pretherapeutic TBRs showed a close correlation to the amount of tumor necrosis induced by polychemotherapy (P < 0.001; Spearman). With a TBR ratio cutoff level of 0.6, all responders and 8 of 10 nonresponders could be identified by PET. In addition, lung metastases of osteosarcoma were detected with FDG PET in 4 patients. CONCLUSION: FDG PET provides a promising tool for noninvasive evaluation of neoadjuvant chemotherapy response in osteosarcoma. This could imply consequences for the choice of surgical strategy, because a limb salvage procedure cannot be recommended in patients nonresponsive to preoperative chemotherapy unless wide surgical margins can safely be achieved.

Transitional cell carcinoma arising in a pyelocaliceal cyst. An unusual cystic renal lesion with cytologic and imaging findings.

The differentiation between benign and malignant cystic lesions of the kidney is a diagnostic challenge. Medical imaging aids in this task, but many cystic renal lesions require further work-up, frequently by computed tomography-guided fine needle aspiration. We report on the pathological findings in a case of moderately differentiated papillary transitional carcinoma, which arose in a pre-existing pyelocaliceal cyst in a 53-year-old man. In the case of this lesion, the distinction between a benign and a malignant renal cyst is blurred. To our knowledge, this is the third such occurrence to be reported and the first to be diagnosed by fine needle aspiration biopsy.

Adenoviral nerve growth factor and beta-galactosidase transfer to spinal cord: a behavioral and histological analysis.

OBJECT: The present study characterizes the time course and loci of gene expression induced by the administration of adenoviral vectors into spinal cord. Although a marked inflammatory response to these vectors occurred, no effect on spinal cord function was seen in the 1st postoperative week. The expression of transgenic genes delivered by viral vectors is being exploited throughout the nervous system. The present study utilized adenoviral vectors containing the Rous sarcoma virus (RSV) promoter and a nuclear localization signal to achieve transgenic expression in mammalian spinal cord. METHODS: Initial experiments utilizing the vector Ad.RSVlacZ (10(12) particles/ml) injected into the region of the central canal resulted in viral gene expression stretching over approximately 1.2 cm of spinal cord. Gene expression was first detected 3 days following viral administration and lasted until postinjection Day 14 with peak expression at Day 7. A variety of cell types in both white and gray matter expressed lacZ. Transgenic expression of the neurotrophin nerve growth factor (NGF) was achieved using injections of Ad.RSVNGF. On histological examination mononuclear inflammatory infiltrate and gliosis were revealed surrounding the injection sites of spinal cords receiving adenovirus but not vehicle. To assess spinal cord function during viral gene expression, animals previously trained in an operant runway task were tested at 7 days postinjection (the peak of viral gene expression) and demonstrated no changes in spinal cord function. CONCLUSIONS: Results of this study using adenoviral neurotrophic gene transfer indicate that it provided an effective tool for the delivery of potentially therapeutic proteins to the injured or diseased spinal cord.

Fluorodeoxyglucose positron emission tomography of soft tissue tumours: is a non-invasive determination of biological activity possible?

Since musculoskeletal tumours comprise a large heterogeneous group of entities with different biological behaviour, clinical diagnosis of such lesions can be very difficult. The aim of this prospective study was to assess the usefulness of 2-[F-18]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) in the non-invasive evaluation of soft tissue tumours. One hundred and two patients with suspected soft tissue neoplasms were investigated by FDG-PET. The uptake of FDG was evaluated semiquantitatively by determining the tumour to background ratio (TBR). All patients underwent biopsy, resulting in the histological detection of 39 high-grade sarcomas, 16 intermediate-grade sarcomas, 11 low-grade sarcomas, 25 benign tumours, 10 tumour-like lesions such as spontaneous myositis ossificans (n = 6) and one non-Hodgkin lymphoma. All lesions except for two lipomas disclosed an increased FDG uptake. Sarcomas showed significantly higher TBR values than latent or active benign lesions (P<0.001) and aggressive benign lesions (P<0.05). Using a TBR cut-off level of 3.0 for malignancy, sensitivity of FDG-PET was 97.0%, specificity 65.7% and accuracy 86. 3%. From our data there are three main conclusions: (1) Except for patients with pseudotumoral myositis ossificans, lesions with a TBR >3 were sarcomas (91.7%) or aggressive benign tumours (8.3%). (2) Tumours with a TBR <1.5 were latent or active benign lesions, exclusively. (3) The group with intermediate TBR values (<3 and >1. 5) comprised primarily latent or active benign lesions, but also four aggressive benign tumours and two low-grade sarcomas. Our data suggest that FDG-PET represents a useful tool for the evaluation of the biological activity of soft tissue neoplasms.

Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis.

UNLABELLED: The aim of this study was to assess the usefulness of PET with 2-18F-fluoro-2-deoxy-D-glucose (FDG), as compared to immunoscintigraphy (IS) with 99mTc-labeled monoclonal antigranulocyte antibodies (AGAbs), in the detection of chronic osteomyelitis. METHODS: Fifty-one patients suspected of having chronic osteomyelitis in the peripheral (n = 36) or central (n = 15) skeleton were evaluated prospectively with static FDG PET imaging and combined 99mTc-AGAb/99mTc-methylene diphosphonate (MDP) bone scanning within 5 days. FDG PET and IS were evaluated in a blinded and independent manner by visual interpretation, which was graded on a five-point scale of two observers' confident diagnosis of osteomyelitis. Receiver operating characteristic (ROC) curve analysis was performed for both imaging modalities. The final diagnosis was established by means of bacteriologic culture of surgical specimens and histopathologic analysis (n = 31) or by biopsy and clinical follow-up over 2 yr (n = 20). RESULTS: Of 51 patients, 28 had osteomyelitis and 23 did not. According to the unanimous evaluation of both readers, FDG PET correctly identified 27 of the 28 positives and 22 of the 23 negatives (IS identified 15 of 28 positives and 17 of 23 negatives, respectively). The area under the ROC curve was 0.97/0.97 (reader 1/reader 2) for FDG PET and 0.87/0.90 for IS, with a high degree of interobserver concordance (K-values were 0.96 for FDG PET and 0.91 for IS). In the central skeleton, the ROC curve area was 0.98/1.00 for FDG PET and 0.71/0.77 for IS (p<0.05). On the basis of ROC analysis, the overall accuracies of FDG PET and IS in the detection of chronic osteomyelitis were 96%/96% and 82%/ 88%, respectively. With regard to the optimal threshold values, sensitivity and specificity were 100%/97% and 95%/95% with FDG PET, compared to 86%/92% and 77%/82% with IS, respectively. CONCLUSION: In the peripheral skeleton, both FDG PET and combined 99mTc-AGAb/99mTc-MDP scanning are appropriate imaging modalities to diagnose chronic osteomyelitis. FDG PET additionally allows reliable differentiation between osteomyelitis and infection of the surrounding soft tissue. In the central skeleton within active bone marrow, FDG PET is highly accurate and superior to AGAb imaging in the diagnosis of chronic osteomyelitis, which frequently presents as a nonspecific photopenic lesion at scintigraphy with labeled white blood cells.

Chronic osteomyelitis: detection with FDG PET and correlation with histopathologic findings.

PURPOSE: To evaluate use of positron emission tomography (PET) with 2-(fluorine-18) fluoro-2-deoxy-D-glucose (FDG) in detection of chronic osteomyelitis. MATERIALS AND METHODS: Thirty-one patients suspected to have chronic osteomyelitis in the peripheral (n = 21) or central (n = 10) skeleton were evaluated prospectively with FDG PET. Analysis of the receiver operating characteristic curve was performed. The final diagnosis was made by means of bacteriologic culture of surgical specimens and histopathologic analysis. RESULTS: FDG PET allowed identification of 17 of 18 patients with osteomyelitis and 12 of 13 without osteomyelitis. There was one false-positive and one equivocal result. The area under the ROC curve was 0.96 for all patients, 1.00 for patients suspected to have osteomyelitis in the peripheral skeleton, and 0.88 for patients suspected to have osteomyelitis in the central skeleton. The overall accuracy of FDG PET was 97% with a high degree of interobserver concordance (kappa = 0.93). The overall sensitivity and specificity were 100% and 92%, respectively. CONCLUSION: FDG PET enables noninvasive detection and demonstration of the extent of chronic osteomyelitis with a high degree of accuracy. Especially in the central skeleton within active bone marrow, FDG PET is highly accurate and shows great promise in diagnosis of chronic osteomyelitis.

Cardiovascular complications of malignant carcinoid disease.

Carcinoid tumors are endocrinologic malignancies often associated with a characteristic syndrome-the malignant carcinoid syndrome. Cardiovascular manifestations of this rare illness result from unique pathophysiologic characteristics, are associated with poor prognosis, and are difficult to treat medically. The hemodynamic consequences of this disease present unique management problems perioperatively. New pharmacologic and surgical therapies for malignant carcinoids have improved quality of life for patients to the extent that carcinoid heart disease now has more impact on morbidity and mortality rates. Cardiologists may be called on to diagnose and treat this rare cardiac disease. We review, for consulting cardiologists, the pathophysiologic characteristics, cardiovascular manifestations, and management of this disease.

Transnasal transesophageal echocardiography.

Transesophageal echocardiography has been used as a diagnostic tool in the critical care unit. However, long-term serial evaluation of ventricular function with transesophageal echocardiography is difficult because of the current probe sizes and intolerance to prolonged oral intubation. We performed 139 intubations (64 oral and 75 transnasal) with a new prototype probe in 128 patients referred for transesophageal echocardiography. Transnasal intubation with the prototype probe was possible in 63/75 attempts. Oral intubation was successful in all 64 attempts. Patients tolerated transnasal intubation well when mildly sedated or awake. Two-dimensional echocardiographic views obtained with the nasal probe were similar to those obtained with a standard monoplane probe. Image quality was rated as good or acceptable in nearly all cases. Transgastric short-axis imaging of the left ventricle combined with acoustic quantification provided stable left ventricular area waveforms. Using custom developed software we showed the feasibility of monitoring left ventricular performance with minimal probe adjustment while graphically displaying and updating left ventricular area and fractional area change. Thus, transesophageal echocardiography with a prototype miniaturized monoplane probe passed transnasally is feasible, safe, and well tolerated by patients. This probe provides excellent two-dimensional echocardiographic images and may allow long-term echocardiographic monitoring of ventricular performance.

Comparative effects of losartan and enalapril on exercise capacity and clinical status in patients with heart failure. The Losartan Pilot Exercise Study Investigators.

OBJECTIVES: This study was designed to determine 1) whether 12-week oral administration of losartan, an angiotensin II receptor antagonist, in patients with heart failure is well tolerated; and 2) whether functional capacity and clinical status of patients with heart failure in whom treatment with an angiotensin-converting enzyme (ACE) inhibitor is replaced with losartan for 12 weeks will remain similar to that noted in patients in whom treatment with an ACE inhibitor is continued. BACKGROUND: Losartan is a specific, nonpeptide angiotensin II receptor antagonist. Although specific receptor blockade with losartan has certain theoretic advantages over nonspecific ACE inhibition, definitive demonstration of comparable effects in patients with congestive heart failure is lacking. METHODS: A double-blind, multicenter, randomized, parallel, enalapril-controlled study was conducted in 116 patients with congestive heart failure (New York Heart Association functional classes II to IV) and left ventricular ejection fraction < or = 45% previously treated with stable doses of ACE inhibitors and diuretic agents, with or without concurrent digitalis and other vasodilators. After a baseline exercise period, open-label ACE inhibitors were discontinued, and patients were randomly assigned to 12 weeks of therapy with losartan, 25 mg/day (n = 38); losartan, 50 mg/day (n = 40); or enalapril, 20 mg/day (n = 38). Drug efficacy was evaluated by changes in maximal treadmill exercise time (using a modified Naughton protocol), 6-min walk test, left ventricular ejection fraction and dyspnea-fatigue index. Safety was measured by the incidence of clinical and laboratory adverse experiences. RESULTS: The treadmill exercise time and the 6-min walk test did not change significantly after replacement of ACE inhibitor therapy with losartan. Similarly, a significant change was not observed in either the dyspnea-fatigue index or left ventricular ejection fraction at the end of double-blind period relative to baseline. CONCLUSIONS: Losartan was generally well tolerated and comparable to enalapril in terms of exercise tolerance in this short-term (12-week) study of patients with heart failure. The clinical effects of long-term angiotensin II receptor blockade compared with ACE inhibition remain to be studied.

An echocardiographic approach to the assessment of aortic stenosis.

An accurate echocardiographic assessment of aortic stenosis is critical for the cost-effective diagnosis and management of patients with the clinical suspicion of this diagnosis. Although the concepts involved in the echocardiographic determination of aortic pressure gradients and valve areas are relatively simple, acquisition of the data required to perform these calculations can at times be technically challenging. After reviewing the clinical signs and symptoms and the hemodynamics of aortic stenosis, this article reviews in detail the technical aspects involved in obtaining accurate gradients and valve areas emphasizing potential pitfalls.