Management of renal angiomyolipoma in patients with tuberous sclerosis complex.

Renal angiomyolipomas are common in patients with tuberous sclerosis complex (TSC), and the risk of severe haemorrhage from these angiomyolipomas can become substantial. This case illustrates a potentially life-threatening condition due to the development of a large aneurysm within an angiomyolipoma, which was discovered within 14 months of her screening renal ultrasound scan. Renal arterial embolisation and renal sparing surgery resulted in good recovery. Clear guidelines for the screening, surveillance, and treatment of angiomyolipomas in patients with TSC are required. This includes the appropriate frequency of surveillance for patients in different age groups and at different stages of angiomyolipoma development, based on a growing knowledge of the natural history of this condition, since growth of renal angiomyolipomas can be rapid and asymptomatic. Computed tomography or magnetic resonance imaging may be required to demonstrate complications in large lesions, as three ultrasound examinations in this patient failed to detect the large aneurysm which had developed. Angiogenesis inhibitors could potentially play a role in preventing the development of angiomyolipomas, which could improve the prognosis for patients with TSC and therefore warrants investigation through phase II/III clinical trials.

The influence of actuarial risk assessment in clinical judgments and tribunal decisions about mentally disordered offenders in maximum security.

Research has shown that actuarial assessments of violence risk are consistently more accurate than unaided judgments by clinicians, and it has been suggested that the availability of actuarial instruments will improve forensic decision making. This study examined clinical judgments and autonomous review tribunal decisions to detain forensic patients in maximum security. Variables included the availability of an actuarial risk report at the time of decision making, patient characteristics and history, and clinical presentation over the previous year. Detained and transferred patients did not differ in their actuarial risk of violent recidivism. The best predictor of tribunal decision was the senior clinician's testimony. There was also no significant association between the actuarial risk score and clinicians' opinions. Whether the actuarial report was available at the time of decision making did not alter the statistical model of either clinical judgments or tribunal decisions. Implications for the use of actuarial risk assessment in forensic decision making are discussed.

Auditory neuropathy: case study with hyperbilirubinemia.

Auditory neuropathy (AN) has been described in the literature as presenting with a combination of audiometric findings that include elevated behavioral audiometric thresholds, auditory brainstem response findings that are not consistent with audiometric findings, poor speech recognition, and present otoacoustic emissions (OAEs) and/or cochlear microphonics. Since the availability of clinical OAE testing, AN has come to be identified with increasing frequency; however, incidence and prevalence figures are unavailable. There is a great deal of discussion about the accurate diagnosis of AN, its characteristics, and its treatment. Some of this discussion is occurring on the Internet and over the telephones. The need to continue to provide information in accessible peer-reviewed journals is paramount. Following a review of the literature, a case study is presented of a boy who was diagnosed with AN as a newborn. He experienced hyperbilirubinemia and other neonatal health complications. His educational intervention was managed elsewhere until recently. Information is presented about the progression of the case over a 5-year period that includes audiologic data and communication development results.

Acute safety of beclomethasone dipropionate in a new CFC-free propellant system in asthmatic patients.

Hydrofluoroalkane-134a (HFA-134a) is a new chlorofluorocarbon (CFC)-free propellant for use in metered dose inhalers. It provides a more environmentally friendly alternative to CFC propellants because it does not contain chlorine which is responsible for ozone depletion by CFCs. Beclomethasone dipropionate (BDP) is widely used for inhalation asthma therapy and is most commonly delivered by a CFC propellant system. The present study evaluated the acute safety of BDP formulated with the new propellant (HFA-134a BDP) compared with BDP in a CFC-11/12 formulation by measuring the acute bronchial response in asthmatic patients. The study was conducted as a randomized, single-blind, placebo-controlled, four-period cross-over trial. Asthmatic patients received eight inhalations of four treatment regimens (HFA-134a BDP, 1600 mg total dose; CFC-11/12 BDP, 2000 mg total dose; HFA-134a placebo and CFC-11/12 placebo) in random order over four study days. Forced expired volume in 1 s (FEV1) was measured before and 2, 10, 20, 40 and 60 min after inhalation of the study treatments. The number of coughs was counted from the start of the first inhalation to 60 s after the last inhalation. There were no statistically significant differences between the treatment groups for changes in FEV1, for the number of coughs or for the occurrence or severity of bronchoconstriction. In asthmatic patients withholding bronchodilators, the new HFA-134a BDP propellant system proved as safe and was as well tolerated as the current CFC-11/12 BDP system. The two propellant systems without active drug were also equally well tolerated.

Adverse effects of poor behavior management of an inpatient's difficult behaviors.

Behavior therapy has been shown to improve the functioning of institutionalized clients, but front-line staff often have difficulty implementing behavior therapy techniques. In the case described in this report, staff with inadequate training in behavior therapy inconsistently used negative and positive reinforcement in the attempt to reduce the aggressive behavior of an inpatient diagnosed as having schizophrenia, and the interventions were associated with an increase in assaults and related behavior. The case illustrates the effects of poor behavior management and the importance of data collection in evaluating clinical interventions.

Prediction of conductive hearing loss based on acoustic ear-canal response using a multivariate clinical decision theory.

This study evaluated the accuracy of acoustic response tests in predicting conductive hearing loss in 161 ears of subjects from the age of 2 to 10 yr, using as a "gold standard" the air-bone gap to classify ears as normal or impaired. The acoustic tests included tympanometric peak-compensated static admittance magnitude (SA) and tympanometric gradient at 226 Hz, and admittance-reflectance (YR) measurements from 0.5 to 8 kHz. The performance of individual, frequency-specific, YR test variables as predictors was assessed. By applying logistic regression (LR) and discriminant analysis (DA) techniques to the multivariate YR response, two univariate functions were calculated as the linear combinations of YR variables across frequency that best separated normal and impaired ears. The tympanometric and YR tests were also combined in a multivariate manner to test whether predictive efficacy improved when 226-Hz tympanometry was added to the predictor set. Conductive hearing loss was predicted based on air-bone gap thresholds at 0.5 and 2 kHz, and on a maximum air-bone gap at any octave frequency from 0.5 to 4 kHz. Each air-bone gap threshold ranged from 5 to 30 dB in 5-dB steps. Areas under the relative operating characteristic curve for DA and LR were larger than for reflectance at 2 kHz, SA and Gr. For constant hit rates of 80% and 90%, both DA and LR scores had lower false-alarm rates than tympanometric tests-LR achieved a false-alarm rate of 6% for a sensitivity of 90%. In general, LR outperformed DA as the multivariate technique of choice. In predicting an impairment at 0.5 kHz, the reflectance scores at 0.5 kHz were less accurate predictors than reflectance at 2 and 4 kHz. This supports the hypothesis that the 2-4-kHz range is a particularly sensitive indicator of middle-ear status, in agreement with the spectral composition of the output predictor from the multivariate analyses. When tympanometric and YR tests were combined, the resulting predictor performed slightly better or the same as the predictor calculated from the use of the YR test alone. The main conclusion is that these multivariate acoustic tests of the middle ear, which are analyzed using a clinical decision theory, are effective predictors of conductive hearing loss.

Ultrastructural evaluation of renal cell oncocytomas.

The utility of ultrastructural evaluation of eosinophilic renal cell neoplasms is illustrated by two case studies. The differential diagnosis between granular renal cell carcinoma and renal cell oncocytoma may be difficult. Ultrastructural demonstration of the presence of abundant mitochondria is useful in the definitive diagnosis of fine-needle aspiration specimens, those neoplasms with nuclear pleomorphism, or in patients requiring renal parenchymal sparing surgery.

Twenty-eight-day double-blind safety study of an HFA-134a inhalation aerosol system in healthy subjects.

A 28-day double-blind parallel group study has been conducted to compare the safety and tolerability of HFA-134a, a chlorofluorocarbon-free propellant in a pressurized metered-dose inhaler (MDI A), with a chlorofluorocarbon propellant (MDI C). Sixteen subjects were randomly assigned to receive one of the two MDIs, either four inhalations four times per day for 14 days or eight inhalations four times a day for 14 days, and were then crossed over to the alternative exposure regime with the same propellant for the next 14-day period. No clinically significant changes occurred in blood pressure, heart rate, electrocardiograms, pulmonary function (FEV1, FVC, FEF25-75%), haematology or serum chemistry. One subject in the MDI A group had elevated eosinophil counts throughout the study; there were no other remarkable clinical laboratory data. Fifty six adverse events were related to the study propellants; 34 of these occurred in the MDI C group and 22 in the MDI A group. For each adverse event no statistically significant differences were detected between propellant systems or between exposure levels. The most frequent adverse event was headache, which was reported by four subjects with each propellant system. Blood samples for HFA-134a in the MDI A group were collected on day 28 to measure systemic absorption. Blood levels of HFA-134a were detected in all subjects given this propellant within 1 min post-exposure, and these levels decreased to one-tenth of the original value by 18 min after the start of exposure. The safety and tolerability of an HFA-134a chlorofluorocarbon-free system was demonstrated over 28 days of exposure in healthy subjects. These negative results are clinically important because they indicate it will be safe to proceed with the study of this chlorofluorocarbon-free system in asthmatic patients.

Idiopathic pulmonary hemosiderosis and alveolar hemorrhage syndrome: case report and review of the literature.

The presence of widespread hemorrhage from the microvasculature of the lung into the alveolar spaces defines what is called the "alveolar hemorrhage syndrome", which can occur in association with a wide variety of clinical disorders. The cardinal manifestations of this syndrome include: hemoptysis, unexplained anemia and diffuse alveolar infiltrates on chest roentgenograms. Since the pulmonary features are similar, the diagnosis usually depends on the clinical, laboratory and pathologic evaluations. Early diagnosis and treatment is crucial since the occurrence of pulmonary hemorrhage in this syndrome may represent a catastrophic event with fatal consequences. Idiopathic pulmonary hemosiderosis (IPH) has been identified as a cause of alveolar hemorrhage in a small number of cases, mainly by exclusion criteria. We report a case of a 70-year old man who presented with a 40-year history of intermittent hemoptysis and bilateral upper lobes alveolar infiltrates proved to be secondary to idiopathic pulmonary hemosiderosis. Although the lung apices are frequently spared in IPH, they were the site of the infiltrates in our case. To our knowledge, our patient had the longest survival time ever reported in the literature in adult IPH. A brief review of some of the disorders commonly associated with alveolar hemorrhage is also presented.

Renal hemodynamic and histological consequences of diets high in unsaturated fat, protein or sucrose in obese Zucker rats.

The objective of this study was to determine the long-term effect of different dietary macronutrients on renal hemodynamics in obese Zucker rats. Female obese (fa/fa) Zucker rats were allowed to eat control chow (ObCL) or diets high in unsaturated fat (ObHF), protein (ObHP) or sucrose (ObHS) for a period of 24 weeks. Lean chow fed (LnCL) Zucker rats served as lean controls. After 24 weeks of dietary treatments, glomerular filtration rate (GFR, ml/mg/g, mean +/- SE) of ObHP and ObHS (0.38 +/- 0.06 and 0.27 +/- 0.05) rats were significantly (p < 0.005) lower than ObCL (0.74 +/- 0.05) and ObHF (0.88 +/- 0.1) rats. In a similar manner, the effective renal plasma flow (ERPF, ml/min/g) was significantly (p < 0.005) lower in ObHP and ObHS (1.28 +/- 0.16 and 1.04 +/- 0.2) than ObCL (2.46 +/- 0.31) or ObHF (2.85 +/- 0.25) rats. The ObHF rats appeared "protected" since they had similr GFR and ERPF but less proteinuria and glucosuria than ObCL rats. Histological examination of renal tissue from ObHP and ObHS fed rats revealed significant (p < 0.005) increase in sclerosis relative to ObCL rats. The sclerosis of renal tissue in ObHF was minimized and was found to be similar to ObCL rats. The mean arterial pressure and heart rates were similar in all dietary treated obese Zucker rats. When comparing obese and lean controls, ObCL rats had significantly (p < 0.03) lower GFR (0.74 +/- 0.05 vs 0.92 +/- 0.05) but similar ERPF (2.46 +/- 0.3 vs 2.82 +/- 0.12) than LnCL rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Extremely low birthweight infants at 3 years: a developmental profile.

This study documents the neurodevelopmental outcome at 3 years of 52 of 55 extremely low birthweight (ELBW) survivors (survival rate 49%) born in a tertiary maternity centre from July 1985 through December 1988, and examines more closely the developmental profile of the neurologically normal survivors. At 3 years, 6 (12%) children had severe neurodevelopmental impairment (severe cerebral palsy, blindness, deafness or a General Quotient (GQ) < 70 on the Griffiths Scales), 11 (21%) had mild to moderate impairment and 35 (67%) had no neurosensory impairment and normal development (GQ > or = 85). Significant risk factors for severe impairment were stage 3 or 4 retinopathy of prematurity (odds ratio [OR] 21.5), treatment with postnatal steroids (OR 21), grade III or IV intraventricular haemorrhage (OR 11) and supplemental oxygen at 'term' (OR 6.4). The developmental profile of the 35 neurologically normal children revealed a significant weakness in eye and hand coordination skills and a relative strength in hearing and speech skills. Early recognition of this developmental profile may allow implementation of more appropriate preschool programmes for ELBW children.

Comparative assessment of a new breath-actuated inhaler in patients with reversible airways obstruction.

Twenty-five patients with reversible airways obstruction inhaled salbutamol (200 micrograms) from the standard press and breathe-metered dose inhaler or a new breath-actuated metered dose inhaler (Aerolin in the Autohaler inhalation device; 3M Health Care Ltd.) in a single dose, double-blind, double-dummy, 2-period, cross-over study. Forced expiratory volume in 1 s, forced vital capacity and peak expiratory flow rate were measured in the 4-hour period after inhalation. The equivalence of the two inhaler devices was determined by analysis of the peak change and time to peak, with reference to the initial recorded baselines of the measured parameters. The efficacy of the two devices was very similar. The breath-actuated device is likely to benefit inhaler users who suffer from poor co-ordination of actuation and inhalation with a standard inhaler.

Efficacy and safety of two-year therapy with transdermal clonidine for essential hypertension.

We evaluated the safety and efficacy of transdermal clonidine (TC) in 23 patients with essential hypertension over a two-year period. Fourteen patients achieved control of blood pressure using TC alone. Six patients achieved control with a combination of TC and the diuretic chlorthalidone (CH). Three patients had control with CH alone or did not achieve control with either TC alone or TC plus CH and were dropped from the study. Of the 20 patients remaining in the study, six patients remained on TC or TC plus CH for the two-year study. Ten of the 20 patients quit the study because of skin reactions and four because of other side effects. No clinically significant changes were noted in serum or urinary laboratory parameters. Finally, TC was effective as long-term monotherapy for essential hypertension in only four of our patients. The major limitation is skin-related side effects.

Selenium toxicosis in wild aquatic birds.

Severe gross and microscopic lesions and other changes were found in adult aquatic birds and in embryos from Kesterson Reservoir (a portion of Kesterson National Wildlife Refuge), Merced County, Calif., during 1984. Adult birds from that area were emaciated, had subacute to extensive chronic hepatic lesions, and had excess fluid and fibrin in the peritoneal cavity. Biochemical changes in their livers included elevated glycogen and non-protein-bound sulfhydryl concentrations and glutathione peroxidase activity but lowered protein, total sulfhydryl, and protein-bound sulfhydryl concentrations. Congenital malformations observed grossly in embryos were often multiple and included anophthalmia, microphthalmia, abnormal beaks, amelia, micromelia, ectrodactyly, and hydrocephaly. Mean concentrations of selenium in livers (94.4 ppm, dry weight) and kidneys (96.6 ppm) of birds collected at the Kesterson ponds were about 10 times those found at a nearby control area (8.3 and 12.2 ppm). We conclude that selenium present in the agricultural drainage water supplied to the Kesterson ponds accumulated in the food chain of aquatic birds to toxic concentrations and caused the lesion and other changes observed.

Effect of age on the sensitivity of cell cultures to Clostridium difficile toxin.

The effect of age on the sensitivity of four cell lines, human foreskin fibroblasts (HFS), CHO-K1, HEp-2, and WI-38 to detect Clostridium difficile toxin was tested. This study also addressed the sensitivity of these cell lines as expressed by early toxin detection. Twenty-eight positive and 13 negative patient specimens were tested. Cell cultures were inoculated at ages 3, 4, 5, 6, 7, 9 and 14 days and examined for cytopathic effects at 4, 24, and 48 hours post-inoculation. The sensitivity of three of the four cell cultures to C. difficile toxin decreased as the age of the cell cultures increased. However, the sensitivity of the HFS cell line was not influenced by the age of the culture or the time the assay was read in comparison to the other three cell lines. Five- to six-day-old HFS cell cultures detected 22/28 positive samples within 4 hr after inoculation and 28/28 positive samples by 24 hr post-inoculation.

Isolation of Chlamydia psittaci from naturally infected African clawed frogs (Xenopus laevis).

An inclusion-forming agent was isolated from the livers of commercially raised African clawed frogs (Xenopus laevis) involved in an epizootic of high morbidity and mortality. Original isolation was made in McCoy cells. This agent was identified as Chlamydia psittaci based on the formation of typical intracytoplasmic inclusions which developed within 48 h, were not stained by iodine, and were resistant to sulfadiazine. The isolate from one particular frog (designated as strain 178) was further studied and found to be lethal for 7-day-old embryonated chicken eggs after intra-yolk sac inoculation. This strain was demonstrated not to be pathogenic for mice when inoculated intraperitoneally. The cell culture isolate of C. psittaci was transmitted to uninfected X. laevis, causing disease and death.

Spontaneous and experimental infections of Xenopus laevis with Chlamydia psittaci.

Chlamydial infection was suspected when widespread pyogranulomatous inflammation and large basophilic intracytoplasmic inclusion bodies were evident histopathologically in African clawed frogs (Xenopus laevis) dying of a spontaneous disease of high morbidity and mortality. Organism morphology was determined by electron microscopy of infected hepatic sinusoidal lining cells, and it was characteristic of the unique developmental cycle of a chlamydial agent. Isolation and speciation of the organism was achieved in a McCoy cell culture system. The infected cells were inoculated into disease-free frogs reproducing the disease.