Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty.

INTRODUCTION: Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss. MATERIALS AND METHODS: We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value (SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version. RESULTS: Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6 years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up. CONCLUSION: Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge.

BACKGROUND: Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGMS) have been proven very effective in diabetes management. AIM: This study evaluated the usefulness of these devices during prolonged, intense physical activity in an uncontrolled natural environment away from the clinical research center. DESIGN: Non-randomized, prospective and observational study. METHODS: During the summer, 38 participants with type 1 diabetes crossed the Samaria gorge, the second largest gorge in Europe (17 km). Twenty subjects on CSII combined with real-time CGMS and 18 on multiple daily injections (MDI) combined with professional (retrospective) CGMS participated in the program. All participants were unsupervised during the event. RESULTS: All 38 participants managed to reach the destination point safely. There were no episodes of severe hypoglycemia. The duration of the exercise (mean ±SD) was 6.4 ± 1.3 h. The CSII group exhibited significantly lower hypoglycemic episodes during exercise (0.1 ± 0.3 vs. 0.4 ± 0.6; P = 0.047) as well as lower AUC below 70 mg/dl compared with the MDI, during the 24 h (0.61 ± 0.78 vs. 1.84 ± 1.55; P = 0.007). Individuals on CSII were significantly less likely to develop a hypoglycemic episode during exercise (P = 0.038). Exercise induced nocturnal hypoglycemia was not prevented effectively in neither group. CONCLUSIONS: CSII combined with CGMS is effective in controlling blood glucose levels in type 1 diabetics who perform prolonged strenuous exercise. The use of insulin pump technology in regions with hot Mediterranean climates is safe and can provide protection against exercise-induced hypoglycemia. Development of precise instructions for T1DM who occasionally get involved in exercise activities, requires further studies.

WHICH FACTORS MAY AFFECT THE QUALITY OF LIFE IN PATIENTS WITH TYPE 1 DIABETES MELLITUS USING THE MEDTRONIC VEO CONTINUOUS SUBCUTANEOUS INSULIN INFUSION PUMP?

Continuous Subcutaneous Insulin Infusion (CSII) is considered an effective therapeutic approach to the treatment of patients with Type 1 Diabetes Mellitus (T1DM). Literature offers limited information regarding the quality of life (QoL) in patients using CSII. The aim of the study was to investigate the impact of diabetes related factors on the QoL of patients with T1DM on CSII treatment, in a Greek urban population. A cross-sectional study was conducted on 80 patients with T1DM using CSII. [(Mean±SD) age: 35.9±11.4 years, duration of diabetes: 24.2±10.3 years, BMI: 24.6±3.5kg/m2, duration of Insulin pump use: 7.1±3.9 years, HbA1c: 7.7±1.1%, gender: 37 males-43 females)]. QoL was assessed using the patient self-administered EuroQol EQ 5D validated in Greek. Correlation and regression analyses were performed to examine the relationship between EQ index - EQ VAS scores and diabetes related factors. Hypoglycemia Awareness was measured using Clarke and Gold Score questionnaires, Hypoglycemic Episodes were expressed as number of episodes per week and the Fear of Hypoglycemia was measured using the worry subscale of the Hypoglycemia Fear Survey (HFS-W). Results were as follows: Gold score: 2.8±1.5, Clarke score: 2.8±2.1, Hypoglycemia Fear Score: 20.6±11.2, Number of hypoglycemic Episodes per week: 4.3±2.9, VAS score: 68.7±18.1, EQ index: 0.79±0.24. In univariate analyses QoL was negatively correlated with Hypoglycemic episodes, HbA1c, Hypoglycemia Fear Score and Hypoglycemia Awareness status. After regression analysis, only HbA1c and the number of hypoglycemic episodes per week remained independently related to QoL scores. Prevention of hypoglycemia and glycemic control should be emphasized in order to improve QoL in patients with T1DM with CSII.

The contribution of cluster and discriminant analysis to the classification of complex aquifer systems.

This paper presents an innovated method for the discrimination of groundwater samples in common groups representing the hydrogeological units from where they have been pumped. This method proved very efficient even in areas with complex hydrogeological regimes. The proposed method requires chemical analyses of water samples only for major ions, meaning that it is applicable to most of cases worldwide. Another benefit of the method is that it gives a further insight of the aquifer hydrogeochemistry as it provides the ions that are responsible for the discrimination of the group. The procedure begins with cluster analysis of the dataset in order to classify the samples in the corresponding hydrogeological unit. The feasibility of the method is proven from the fact that the samples of volcanic origin were separated into two different clusters, namely the lava units and the pyroclastic-ignimbritic aquifer. The second step is the discriminant analysis of the data which provides the functions that distinguish the groups from each other and the most significant variables that define the hydrochemical composition of the aquifer. The whole procedure was highly successful as the 94.7 % of the samples were classified to the correct aquifer system. Finally, the resulted functions can be safely used to categorize samples of either unknown or doubtful origin improving thus the quality and the size of existing hydrochemical databases.

The diagnostic value of earlier and later components of Vestibular Evoked Myogenic Potentials (VEMP) in multiple sclerosis.

AIM OF THE STUDY: To evaluate the ability of VEMP to disclose spatial dissemination of Multiple Sclerosis. MATERIALS AND METHODS: Forty-six MS patients with auditory and/or vestibular symptoms were studied. Patients were divided in two groups. Group 1 included 24 patients with brainstem MRI findings, and Group 2 included 22 patients without MRI findings. VEMP and BAEP have been recorded and assessed. RESULTS: Abnormal p13n23 wave was observed in 50%, while unilateral absence or bilateral delay of the n34p44 in 43% of the patients. The overall diagnostic value considering abnormal cases suggested by both first and second VEMP waves was increased to 71%. Statistically significant differences revealed between patients and controls for p13 latency (p=0.018). The p13n23 was abnormal in 7 patients, although MRI scanning did not reveal brainstem lesions. In 9 out of 18 MS patients suffering from unilateral hearing loss, n34p44 was present in the unaffected ears and absent in the affected side, although p13n23 was normal. CONCLUSION: Abnormal VEMP imply the presence of lesions undetected by MRI neuroimaging, which verifies the diagnostic value of the method. Unilateral absence of n34p44 complex was related with sensorineural hearing loss, supporting the hypothesis that n34p44 is of cochlear origin.

Using vestibular evoked myogenic potentials to localise brainstem lesions. A preliminary report.

BACKGROUND: Vestibular Evoked Myogenic Potentials (VEMPs) are saccular responses to acoustic stimuli. They can be recorded from the sternocleidomastoid muscle ipsilaterally to the stimulated ear. Their reflex arc includes the ipsilateral vestibular nuclei. OBJECTIVE: To determine the usefulness of VEMPs in localising brainstem lesions. METHODS: We used VEMPs, Blink Reflex (BR) and Brainstem Auditory Evoked Responses (BAERs) to evaluate six patients presenting with acute ischaemic or haemorrhagic brainstem lesions, or basilar dolichoectasia. RESULTS: MRI in patient one revealed a dorsolateral medullary infarct on the right. VEMP amplitude was reduced ipsilaterally. The R2 BR component was delayed bilaterally upon stimulation of the affected side. Patients two and three had suffered a left lateral lower pontine infarct and a right lateral lower pontine haemorrhage. In patients four and five, MRA revealed dolichoectasia of the basilar artery exerting pressure on the lower lateral pons. VEMP amplitude was reduced ipsilaterally. Patient six had an ischaemic lesion in the right upper lateral pons. The R1, R2i and R2c BR components were delayed ipsilaterally. BAERs waves IV and V were absent on the right. VEMPs were normal. CONCLUSIONS: VEMPs are affected by lesions of the lateral lower pons and upper medulla. Our results suggest that they may be a useful addition in the localisation of such lesions.

Octreotide: a therapeutic option for idiopathic intracranial hypertension.

PURPOSE: To study the effects of octreotide, a somatostatin analogue, in patients with Idiopathic Intracranial Hypertension (IIH). METHODS: We performed a prospective, open-label study of the effect of Octreotide on 26 patients with symptoms and signs of IIH, investigated by brain MRI and lumbar puncture. Octreotide was administered subcutaneously, at an initial dose of 0.3 mg/day; and was gradually increased until headache was relieved (upper-dose limit: 1 mg/day). Treatment with octreotide at 1 mg/day was administered for a maximum of six to eight months and afterwards the dose was gradually tapered. Patients were followed prospectively every month for three years. CSF opening pressure was measured before the treatment was started and again in the first follow-up examination, on month one. In all follow-up visits the presence of papilledema was evaluated by fundoscopy; visual fields and visual acuity were also examined. RESULTS: Overall 24/26 patients improved significantly (92%). Headache was relieved within days (1-10, median 7 days). Papilledema subsided in all 24 patients, in up to two months (35 to 68, median 45 days). Visual disturbances, initially presenting in 20 of our patients, improved in 18 (90%). The mean reduction in CSF pressure after treatment was 20.72A+/-10.7 cmH2O (range 2 to 48). Patients were followed for three years after cessation of treatment. No recurrence of papilledema, or any other symptoms, has been observed. CONCLUSIONS: Octreotide resulted in a significant and sustained improvement of IIH in our patients. These results suggest that it may be an effective alternative to existing treatments for IIH.

Neurophysiological monitoring of brainstem function in a patient with Wallenberg syndrome, using Vestibular Evoked Myogenic Potentials.

PURPOSE: We evaluated the use of Vestibular Evoked Myogenic Potentials (VEMPs) in the assessment of neural function, following medullary lesions. METHODS: A 54-year-old male presented with symptoms and signs typical of right lateral medullary (Wallenberg) syndrome. He underwent brain MRI and three successive neurophysiological investigations, which included VEMPs, Brainstem Auditory Evoked Responses (BAERs) and the blink reflex. RESULTS: VEMPs amplitude on the left (unaffected) side was 256.8 microv in the first investigation and remained approximately equal to that value in the following two ones. Their amplitude on the right (affected) side was 37.9 microv, 154.2 microv and 235.2 microv correspondingly. At the same time vertigo, diplopia and nystagmus gradually improved. Right blink reflex comprised a normal R1, but delayed R2 ipsilateral and R2 contralateral responses, which remained unaltered during the follow-up period. Brain MRI disclosed a right dorsolateral medullary infarct. CONCLUSIONS: VEMPs amplitude progressively increased, parallel to the improvement of vestibular symptoms. The blink reflex evolved differently, while BAERs were not affected. As the three evoked responses are mediated by separate neural circuits, they provide information on different aspects of brainstem function. Thus, VEMPs seem to be a useful method that complements existing ones in the assessment of brainstem lesions.

Underutilization of aspirin in hemodialysis patients for primary and secondary prevention of cardiovascular disease.

BACKGROUND: Patients on hemodialysis are at high risk for cardiovascular disease (CVD). Aspirin is an established therapy for primary and secondary prevention of CVD that may be underutilized in hemodialysis patients. To better understand the use of aspirin in hemodialysis patients, we examined the experience of an urban hemodialysis center. Guidelines for use as well as associated risks and benefits are reviewed. METHODS: Medical records for patients receiving hemodialysis treatment at our center (New York City, USA) in May 2004 were reviewed for aspirin use, presence of CVD, and potential contraindications to aspirin therapy. CVD was defined as a history of coronary artery disease, ischemic stroke, transient ischemic attack, or peripheral vascular disease. Potential contraindications to aspirin therapy included history of clinically significant bleeding or increased risk of bleeding, aspirin allergy and routine treatment with other anticoagulants. RESULTS: 176 patients were eligible for the study and 172 (98%) were included. Although 74 patients had a history of CVD, only 38 (51 %) of these were treated with aspirin. Among patients with a history of CVD who were not treated with aspirin, 19 (53%) had no identifiable contraindications to aspirin therapy for secondary prevention of CVD. Ninetyeight patients had no history of CVD, and 18 (18%) of these were treated with aspirin. Of patients without a history of CVD who were not treated with aspirin, 57 (71%) had no identifiable contraindications to aspirin therapy for primary prevention of CVD. CONCLUSIONS: Aspirin is underutilized in hemodialysis patients for the primary and secondary prevention of CVD. Given the high risk of CVD in hemodialysis patients, therapy with aspirin may be of significant benefit and prospective studies of aspirin therapy are needed.

Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns.

BACKGROUND: Idiopathic focal segmental glomerulosclerosis (FSGS) is one of the leading causes of the nephrotic syndrome in adults and an important cause of end-stage renal disease. Its incidence has dramatically increased in the last two decades and it is especially prevalent among black patients. The trend of FSGS incidence has not been reported beyond 1997. METHODS: We retrospectively reviewed all renal biopsies performed at our institution between 1986 and 2002 and identified patients with diagnoses consistent with primary glomerulopathy (PG), which included: minimal-change disease (MCD), idiopathic focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MGN), IgA nephropathy (IgA), membrano-proliferative glomerulonephritis (MPGN) and mesangioproliferative glomerulonephritis. Patients with possible secondary causes for their renal disease were excluded. Clinical data at the time of biopsy and follow-up data were collected and analyzed. RESULTS: During the period from January 1986-December 2002, 299 renal biopsies were performed and 132 patients were diagnosed with PG. FSGS was the most common form of PG representing 37.8% of all PG followed by IgA 27.3%, MGN 16.6% and MCD 9.1%. Among FSGS patients 59% were females, 64% had nephrotic range proteinuria and 54% had the nephrotic syndrome. Mean serum creatinine was 2.0 +/- 0.2 mg/dl and mean protein excretion was 6.1 +/- 1.0 g/day. The incidence of FSGS increased from 19.3% (1986-1991) and 16.6% (1992-1997) to 58.5% in the period from 2002. The increase occurred among black and Hispanic patients (33.3-79.2%) as well as white patients (12.5-51.5%). Black and Hispanic patients with PG presented for renal biopsy at a significantly younger age than white patients (p = 0.003), with mean age 37.5 +/- 2.0 years vs. 50.3 +/- 1.8 years. White FSGS patients were significantly older than white non-FSGS patients (mean age 56.4 +/- 3.2 years vs. 48.0 +/- 2.0 years, p = 0.03). Black and Hispanic FSGS patients were also older when compared to their non-FSGS counter-parts (mean age 40.6 +/- 2.8 years vs. 32.1 +/- 2.0 years, p = 0.04). When patients were stratified by age (< 45 years and > or = 45 years), FSGS was the most common diagnosis in both age groups among black and Hispanic patients (55.1% and 88.8%) but only among older white patients (36.2%). CONCLUSIONS: The incidence of FSGS as a proportion of PG in our population has increased markedly in the most recent time period analyzed (1998-2002). The increase has occurred among both white and black and Hispanic patients. We also found that FSGS was most prevalent in patients > or = 45 years.

Closure of the abdominal midline fascia: meta-analysis delineates the optimal technique.

The current surgical literature has not clearly demonstrated an optimal technique for abdominal closure. Prospective randomized studies published between 1980 and 1998 were analyzed and the relevant data derived from those studies were pooled for statistical evaluation. The outcome variables of dehiscence, infection, hernia formation, suture sinus formation, and pain were studied and the probability of their occurrence in association with different techniques was calculated. In relation to the outcome features of dehiscence and infection no statistically significant difference was seen when absorbable suture material was compared with nonabsorbable material. In regard to the probability of hernia formation no statistically significant difference was seen when monofilament absorbable material was compared with nonabsorbable material. There was, however, a higher incidence of hernia formation when braided absorbable suture material was used. In addition there was a higher incidence of incision pain and suture sinus formation when nonabsorbable suture material was used. Absorbable monofilament suture material is superior to both absorbable braided and nonabsorbable suture for abdominal fascial closure. A continuous mass (all-layer) closure with absorbable monofilament suture material is the optimal technique for fascial closure after laparotomy.

Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily.

BACKGROUND: Surgical incisions after appendectomy for complicated (gangrenous or perforated) acute appendicitis are often managed with delayed closure (DC) rather than primary closure (PC). This study synthesizes the results of other studies in the surgical literature and supports the routine use of PC. METHODS: Studies dealing with complicated appendicitis were reviewed to assess the results of PC in comparison with DC. The rate of incision (wound) infection in groups of patients managed by PC and DC were compared with the use of a statistical technique that defined the probability of expected results by incorporating data derived from all of the various study groups. RESULTS: Of the 2532 patients who had been treated for complicated appendicitis and who were assessed, 1724 patients underwent PC and 808 patients underwent DC. The rate of incision infection was 4.7% and 4.6% in the PC and DC groups, respectively. With a 95% confidence interval, there was no demonstrable difference between the 2 types of operative site management (P < .01). CONCLUSIONS: PC of the skin and subcutaneous tissue after appendectomy for gangrenous or perforated appendicitis, combined with the use of antibiotic therapy in the perioperative period, is not associated with an increased risk of incision infection when compared with DC.

Perceived value of the American Board of Surgery certificate: a survey of 2,000 Fellows of the American College of Surgeons.

BACKGROUND: This study was undertaken to identify perceptions of surgeons of the value of the American Board of Surgery (ABS) certificate. STUDY DESIGN: Two-thousand Fellows of the American College of Surgeons received a 30-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a 5-point scale in the areas of professional recognition, personal satisfaction, court proceedings, job security, mobility, and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of surgical knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed. RESULTS: Return response rate was 37.2%. The ABS certificate was perceived to be most valuable in obtaining an academic or a clinical position and playing a significant role in court proceedings. It was perceived as least valuable in indicating breadth of knowledge and clinical competence. Sixty-seven percent responded that certified surgeons should earn more, and 49% estimated the certificate's lifetime financial value as more than $500,000. Sixty-two percent of surgeons approved of continuing the recertification process every 10 years. CONCLUSIONS: The ABS certificate is perceived as an objective credentialing instrument that affords diplomates power, status, an opportunity to obtain an academic or clinical position, job mobility, protection in court proceedings, and greater income. Although it is perceived as an instrument that could aid a career, it is not viewed as an indicator of a person's clinical competence.

The Perceived Value of the American Board of Anesthesiology Certificate: A Survey of 2,000 Anesthesiologists.

BACKGROUND: The present study was undertaken in order to identify anesthesiologists' perceptions regarding the value of the ABA certificate. METHODS: 2,000 anesthesiologists received a 31-item survey designed to identify their demographics and their assessments of the functional and financial value of the certificate. Functional value was assessed using a five-point scale in the domains of professional recognition, personal satisfaction, job security, mobility and advancement, whether the certificate was necessary to obtain an academic or a clinical position, and whether it served as an indicator of depth or breadth of anesthesia knowledge or of clinical competence. Perceived professional lifetime financial value of the certificate was also assessed. Return response rate was 45.4%. Data were analyzed using descriptive statistics and student's t-tests. RESULTS: The ABA certificate was perceived to be most valuable in obtaining an academic position (3.4 ± .9) and least valuable in indicating clinical competence (1.6 ± 1.2). Certified anesthesiologists consistently ascribed greater value to it than non-certified ones (p<.001) on all but the academic domain. No gender differences were observed except that females attributed a greater value to the certificate as a requisite for achieving job security. Sixty percent responded that certified anesthesiologists should earn more than non-certified ones and 54% ascribed to a professional lifetime financial value of over $100,000 to ABA certification. CONCLUSIONS: Although perceived as an objective credentialing instrument which could aid one's career, the ABA certificate was not viewed as an indicator of clinical competence.

Indications for surgical treatment of angioaccess-induced arterial "steal".

BACKGROUND: Arterial "steal" is a well-known complication following proximal arteriovenous (AV) fistula, but its manifestations comprise a wide spectrum of symptoms and there are no clear indications for those patients who need surgical repair. STUDY DESIGN: Among 180 consecutive AV fistulas of various configurations, with the brachial artery as the donor artery in all patients, 111 patients were studied retrospectively (group A) and 69 patients were studied prospectively (group B). Patient records were reviewed in group A, and the decision for surgical correction of limb-threatening steal was based on clinical grounds only. In group B, all patients were followed prospectively; postoperative systolic blood pressure measurements were obtained, and a systolic pressure index (SPI) was calculated (postoperative forearm systolic pressure divided by contralateral forearm systolic pressure). In patients with an SPI < 0.6, nerve conduction studies (NCS) were performed. The decision for operation in this group was based on clinical examination, SPI, and NCS. RESULTS: Seven patients were operated on for steal-induced limb-threatening ischemia; in all seven patients, ischemia developed immediately after access construction. One additional patient with mild symptoms and deterioration in repeated NCS was considered a candidate for ischemic monomelic neuropathy and was successfully operated on 1 month later. The ligation-bypass technique was used in all patients, consisting of arterial ligature distal to the takeoff of the graft and short arterial bypass from a point proximal to the inflow of the access to a point just distal to ligation. In 94% of the patients, some degree of distal ischemia was detected (SPI < 0.8); patients with SPI < 0.5 were most likely to have impaired NCS. CONCLUSIONS: Steal-induced limb-threatening ischemia necessitating immediate surgical repair occurred in 3.9% (7 of 180) of our patients. The decision for surgical correction of steal should be based on clinical examination. Nerve conduction studies may be useful in patients who have an SPI value < 0.5 to detect candidates who might develop ischemic monomelic neuropathy. In similar patients, surgical treatment of steal should be offered.

Auditory event related potentials in patients with epilepsy on sodium valproate monotherapy.

OBJECTIVES: The effects of antiepileptic drugs on event related potentials (ERPs) have been studied, but with contradictory results. In this study we examine the effect of sodium valproate (VPA) on ERPs in patients with epilepsy. MATERIALS AND METHODS: Auditory event related potentials were recorded in 40 patients with idiopathic generalized epilepsy, 20 on monotherapy with sodium valproate (VPA), 20 on monotherapy with carbamazepine and 20 age and sex matched controls. All subjects performed a simple auditory discrimination task in which a target tone was presented on 20% of the trials. RESULTS: Mean P3 latency of the VPA group was significantly prolonged but not in carbamazepine group and healthy controls. CONCLUSION: We conclude that VPA monotherapy has an effect on P300 latency in patients with epilepsy. This difference might be attributed to effects of treatment with VPA and may clarify in the future the mechanism of P300.

Decreased intrinsic factor secretion in AIDS: relation to parietal cell acid secretory capacity and vitamin B12 malabsorption.

AIDS-associated gastric secretory failure has been characterized by decreased secretion of acid, pepsin, and gastric juice volume. To determine whether decreased intrinsic factor secretion and vitamin B12 malabsorption occur in this entity, we performed prospective measurements of maximal acid output, intrinsic factor output, vitamin B12 absorption, serum vitamin B12, and holotranscobalamin II in 10 consecutive AIDS patients. Four of 10 patients had low maximal acid output, i.e., < or = 1.5 mEq/h (control = 12.8 +/- 9.0, range 2.5-25 mEq/h). Four patients had low intrinsic factor output, i.e., < or = 1.1 microgram/h (control = 8.2 +/- 6.9, range 3.1-19.4 micrograms/h). One patient with low intrinsic factor output had low serum vitamin B12 and a Schilling test consistent with pernicious anemia. A second patient with very low intrinsic factor output (0.16 micrograms/h) had low parts I and II Schilling tests; malabsorption most likely resulted from both low intrinsic factor secretion and ileal disease. One of three vitamin B12 malabsorbing patients, with normal serum vitamin B12, had low holotranscobalamin II, 25 pg/ml (control holotranscobalamin II = 76 +/- 44, range 44-152 pg/ml). Maximal acid output and intrinsic factor output did not correlate in AIDS (r = 0.36, p = 0.30) in contrast to the expected correlation in controls (r = 0.91, p = 0.03). We conclude that low intrinsic factor secretion is common in AIDS and contributes to vitamin B12 malabsorption. Decreased parietal cell secretion of intrinsic factor and acid may occur independently in human immunodeficiency virus-associated gastric secretory failure. Low holotranscobalamin II, an early manifestation of vitamin B12 malabsorption, results in decreased delivery to vitamin B12-dependent tissues prior to depletion of serum vitamin B12. Regular supplementation with vitamin B12 may therefore be warranted in patients with advanced HIV infection.

A survey of 800 patients' knowledge, attitudes, and concerns regarding anesthesia.

The present study was undertaken to assess patients' knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients' perceptions of the anesthesiologist's training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed. Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patient's sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologist's role in perioperative care should improve patient confidence.

Morphometric and freeze-fracture studies on peripheral nerve in shiverer mice.

Observations have been made on the peripheral nerves of shiverer (shi/shi) mice in comparison with control animals. Although this mutant lacks P1 myelin basic protein in peripheral and central myelin, myelin is defective only in the central nervous system. No ultrastructural abnormalities were observed in the shiverer nerves. Myelin spacing was normal. The density and distribution of intramembranous particles on the E and P faces of myelin and in the axolemma of myelinated and unmyelinated axons did not differ between the shiverer and control mice. Morphometric studies showed that external myelinated fiber diameter was significantly less and that myelin thickness was slightly but significantly greater in relation to axon diameter in the shiverer mice, suggesting a minor degree of axonal atrophy. It is concluded that P1 protein is not necessary for the formation and maintenance of the normal structure of peripheral myelin. The failure to detect differences in intramembranous particle density in myelin between shiverer and control mice indicates that P1 protein is not detected in freeze-fracture preparations.

Stature and longitudinal growth in thalassemia major. A study of 229 Greek patients.

A high percentage of Greek children with homozygous b-thalassemia were short and had a lag in growth, though some severely affected attained normal height. Bone age lagged significantly behind the chronologic age, even in those with normal height for their age. A longitudinal study demonstrated an initial normal growth velocity which decreased after the age of six for males and eight for females. No patient had a spurt of growth at adolescence. Height gain continued up to the age of 21 and then ceased. Statistical analysis with a multiple regression equation showed a significant relationship between the age and height of the patients. Low hemoglobin levels and severity of the disease seemed to hinder normal growth, but neither relationship was statistically significant.