Cardiac tamponade following minimally invasive direct coronary artery bypass.

We report a case of cardiac tamponade resulting in a death following minimally invasive direct coronary artery bypass. Despite absence of clinical symptoms at the time of hospital discharge, cardiac tamponade physiology may have been evident on close evaluation of Doppler studies of the left internal mammary artery. Performance of a predischarge transthoracic echocardiogram may have been confirmatory and lifesaving.

Follow-up of adult patients with atopic eczema treated with Chinese herbal therapy for 1 year.

Adult patients with severe atopic eczema who had completed a double-blind placebo-controlled crossover trial of a specific formulation of Chinese herbal therapy were offered continued therapy for 1 year. Of 31 patients who completed the original placebo-controlled study and after a washout period and 2 months of further treatment, 17 continued treatment (group 1), 11 chose not to continue treatment (group 2), one was lost to follow-up and two patients originally in group 1 decided to stop treatment and became pregnant. At the end of the year, 12 of the patients in group 1 had greater than 90% reduction and the remaining five had greater than 60% reduction in clinical scores compared with baseline values. Clinical scores of patients in group 2 gradually deteriorated so that by the end of the year the difference between groups 1 and 2 was highly significant (P = 0.005 and P = 0.002 for erythema and surface damage, respectively). At the end of the year no patient in group 1 felt able to discontinue treatment permanently, but eight patients were on an alternate-day regimen by 6 months and remained on this regimen until the end of the year, and seven were able to control their eczema with a 1 in every 3 day treatment by the end of the year. The remaining two patients continued on daily treatments. Toxicology screening revealed no abnormalities in either full blood counts or biochemical parameters in any patient on continued treatment. Improvement in disease was not associated with any significant change in serum IgE level or peripheral blood lymphocyte subsets.(ABSTRACT TRUNCATED AT 250 WORDS)

One-year follow up of children treated with Chinese medicinal herbs for atopic eczema.

The opportunity to continue treatment was offered to the parents of 37 children who had completed a double-blind placebo-controlled trial of a specific formulation of Chinese medicinal herbs for atopic eczema. The parents elected for continued treatment in every case, and the progress of the children was monitored over the following 12 months. The aim was to achieve a substantial clinical improvement, and thereafter to reduce treatment frequency progressively while maintaining this benefit. At the end of the year, 18 enjoyed at least 90% reductions in eczema activity scores, and five showed lesser degrees of improvement. Fourteen children withdrew from the study, 10 due to lack of response, and four because of unpalatability of treatment or difficulty in the preparation of treatment. By the end of the year, seven of the children were able to discontinue treatment without relapse. The other 16 required treatment to maintain control of their eczema, but only four of these still required daily treatment. Asymptomatic elevation of serum aspartate aminotransferase to 7-14 times normal values was noted on one occasion in two children whose eczema was so well controlled that the therapy was stopped. Liver function tests were normal 8 weeks later. We conclude that Chinese medicinal herbs provide a therapeutic option for children with extensive atopic eczema which has failed to respond to other treatments. In the medium term, it proved helpful for approximately half the children who originally took part in our placebo-controlled trial. The possibility that it may provoke hepatic abnormalities requires further study.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral psoralen photochemotherapy in severe childhood atopic eczema: an update.

Over a 6-year period, oral psoralen photochemotherapy (oral PUVA) has been used to treat 53 children (mean age 11.2 years) with severe atopic eczema unresponsive to other therapy. Twice-weekly treatment resulted in clearance or near-clearance of disease in 39 (74%) after a mean of 9 weeks. Thirty-two (82%) of these 39 children were subsequently able to achieve remission of disease following gradual withdrawal of treatment; the mean duration of treatment to remission was 37 weeks; the mean cumulative UVA dose was 1118J/cm2, and the mean number of treatments was 59. Twenty-two remain in remission a year after discontinuing treatment. Short- and medium-term adverse effects, other than occasional intolerance of treatment, have not been prominent. Despite anxieties about possible long-term hazards, it is our view that oral PUVA is justified in a small proportion of older children with disabling atopic eczema. We believe that it has substantial advantages over other therapeutic options in selected cases, particularly in providing improved growth and an opportunity for sustained remission.

Efficacy of traditional Chinese herbal therapy in adult atopic dermatitis.

There has been considerable interest in traditional Chinese herbal therapy (TCHT) as a new treatment for atopic dermatitis. To establish the efficacy and safety of this treatment, a daily decoction of a formula containing ten herbs that has been found to be beneficial in open studies was tested in a double-blind placebo-controlled study. 40 adult patients with longstanding, refractory, widespread, atopic dermatitis were randomised into two groups to receive 2 months' treatment of either the active formulation of herbs (TCHT) or placebo herbs, followed by a crossover to the other treatment after a 4-week washout period. The main outcome measures were extent and severity of erythema and surface damage as judged by standardised body scores. The patients' own assessments of the overall response to treatment were also sought. The geometric mean score for erythema at the end of active treatment was 12.6 (95% confidence interval [CI] 5.9 to 22.0) and at the end of the placebo phase was 113 (65 to 180). The geometric mean score for surface damage was 11.3 (5.8 to 21.8) and 111.0 (68 to 182), respectively. The 95% CI for the mean geometric ratio for the two values with active treatment was 0.04 to 0.22 for erythema (p less than 0.0005) and 0.04 to 0.27 for surface damage (p less than 0.0005). Of the 31 patients who completed the study and expressed a preference, 20 preferred that phase of the trial in which they received TCHT whereas 4 patients preferred placebo (p less than 0.02). There was a subjective improvement in itching (p less than 0.001) and sleep (p less than 0.078) during the TCHT treatment phase. No side-effects were reported by the patients although many commented on the unpalatability of the decoction. TCHT seems to benefit patients with atopic dermatitis. Palatability of the treatment needs to be improved and its safety assured.

A controlled trial of traditional Chinese medicinal plants in widespread non-exudative atopic eczema.

Severe and widespread atopic eczema often fails to respond adequately to currently available therapies. Following the observation of substantial benefit in patients receiving oral treatment with daily decoctions of traditional Chinese medicinal plants, we undertook a placebo-controlled double-blind trial of a specific prescription formulated for widespread non-exudative atopic eczema. Forty-seven children were given active treatment and placebo in random order, each for 8 weeks, with an intervening 4-week wash-out period. Thirty-seven children tolerated the treatment and completed the study. Response to active treatment was superior to response to placebo, and was clinically valuable. There was no evidence of haematological, renal or hepatic toxicity. These findings anticipate a wider therapeutic potential for traditional Chinese medicinal plants in this disease, and other skin diseases.

Oral, skin and bone multisystem Langerhans cell histiocytosis and its response to etoposide--a case report.

We present a young man with the classical features of multisystem Langerhans cell histiocytosis (LCH), with emphasis on his disability and demonstrate his dramatic response to Etoposide when other treatments had clearly failed. We review the literature regarding oral and bone involvement in this disease and relate it to long term prognosis.

Topical nitrogen mustard: an effective treatment for cutaneous Langerhans cell histiocytosis.

In 16 children with multisystem Langerhans cell histiocytosis (mean age 22 months, range 5 to 36 months) severe symptomatic skin involvement was treated with topical nitrogen mustard (mechlorethamine hydrochloride). In each case, rapid clinical improvement occurred within 10 days; subsequent complete healing was observed in 14 children, and partial healing in 2 others in whom treatment was a component of palliative care. Mean duration of treatment was 3.5 months (range 2 to 6 months). Systemic treatment was averted in 11 patients because response to topical therapy was so favorable, but bone marrow or respiratory failure led to a fatal outcome in 5 other patients. Adverse effects were minimal. One patient developed contact allergy to topical nitrogen mustard after 2 years of intermittent therapy, but was successfully desensitized and was then able to continue treatment. We conclude that the topical application of nitrogen mustard is an effective treatment for cutaneous Langerhans cell histiocytosis. Although adverse effects were minimal in the short term, there remains concern about the possibility of long-term cutaneous carcinogenicity.

Are strokes predictable with noninvasive methods: a five-year follow-up of 303 unoperated patients.

To determine the correlation between the degree of internal carotid arterial stenosis demonstrated by noninvasive tests and the risk of subsequent stroke, 303 consecutive patients who underwent cerebrovascular evaluation with the Hokanson ultrasonic arteriograph were reviewed retrospectively. Ninety percent of the patients were followed up for 5 years or until the time of death. Stroke occurred in 41 (13.5%) patients. There was a significant correlation (p = 0.04) between the incidence of stroke and severity of disease: greater than or equal to 50% stenosis (19%), 0% to 49% stenosis (11%), and no stenosis (10%). Stroke as a presenting complaint carried the highest risk of subsequent neurologic defect (24%), but the risk in patients without symptoms was appreciable (15%). Life-table analysis indicated that the incidence of stroke was low (less than 3%) in the asymptomatic and nonhemispheric group during the first 2 years after evaluation when the degree of stenosis was less than 50%. Thereafter, the stroke rate increased. Half the deaths were due to myocardial infarction; the risk of death from cardiac causes was doubled in patients with greater than 50% stenosis. It is concluded that the demonstration of hemodynamically significant stenosis does select a group of patients at increased risk for subsequent stroke and myocardial infarction, but lesser degrees of stenosis do not exclude future neurologic events.

Cancer family syndrome manifested in an extended kindred.

A large midwestern kindred exhibiting the CFS is described. In the branches of the family identified as "cancer-prone," malignant lesions of the colon, endometrium, ovary and skin have persisted through as many as five successive generations. In all, 29 family members have had 43 primary malignant growths of the CFS target organs. Eighty-three per cent of these lesions were colonic in origin. Cancers in these family members almost always occur at young ages (x = 40 years), and it is not uncommon for family members to have a second, third or even fourth primary malignant lesion develop. In branches determined "cancer-resistant," only isolated cancers have been diagnosed. Recommendations on the management of families, such as this one, are presented.

Report of a family with cancer family syndrome.

A report of the history and management of colonic cancer in two brothers with Cancer Family Syndrome is presented. An analysis is made of the prevalence of colonic and endometrial cancer in this family. The risk to the progeny of affected and unaffected individuals is discussed, and recommendations for screening for early signs of cancer are offered. [Key words: Cancer, colonic, familial; Cancer Family Syndrome.