Injuries from interpersonal violence presenting to a rural health center in Western Kenya: characteristics and correlates.

OBJECTIVE: To define the scope of injury due to interpersonal violence in a medium-sized town in Western Kenya. DESIGN: Prospective, cross-sectional data collection and analysis. SETTING/SUBJECTS: Data were prospectively collected on all injured patients (n = 562) presenting to a health center in Western Kenya, 2002-2004. Age, gender, type, and severity of injury, relationship to assailant, disposition, and clinician's suspicion of alcohol use were recorded. MAIN OUTCOME MEASURES: Number of injuries due to interpersonal violence; correlation of gender, alcohol use, relationship to assailant, and type of injury. RESULTS: Interpersonal violence caused 43% of all injuries. Men and women were equally likely to suffer violent injuries (42% vs 45%); however, women were more likely to suffer injury from domestic violence (4.7% vs 7.0%) and sexual assault (0% vs 3.5%). Men and women were equally likely to know their assailant. Women were more likely to be injured by a spouse/partner (19% vs 1.3%), whereas men were more likely to be injured by an acquaintance (29% vs 16%). Alcohol use was more often suspected for victims of violent, as opposed to unintentional, injury (45% vs 16%). Men with violent injuries were more likely than women to be suspected of having used alcohol (51% vs 35%). CONCLUSIONS: Interpersonal violence is a leading cause of injury in Western Kenya. Although men and women are equally likely to be assaulted, women are more likely to be injured by a spouse, and men by an acquaintance. Alcohol use is common among those who suffer violent injuries in this population.

Modulation of an idioventricular rhythm by vagal tone.

A 28 year old man with a stable permanent idioventricular rhythm of 80 to 85 beats/min, with all the characteristics of a pacemaker, is described. This pacemaker was slowed by maneuvers that enhanced vagal tone, including carotid sinus massage, the postrelease phase of the Valsalva maneuver and phenylephrine. The pacemaker was also slowed by a cholinesterase inhibitor (edrophonium hydrochloride) and accelerated by a muscarinic receptor blocking drug (hyoscine butylbromide). The actions of these maneuvers and agents were independent of sympathetic tone as propranolol pretreatment did not alter their effects. Similarly, propranolol did not affect the pacemaker rate. The pacemaker was not dependent on a slow inward current because verapamil did not affect its rate. The pacemaker accelerated in response to increased sympathetic tone induced by exercise and upright tilting and to the adrenergic agonist isoproterenol. The pacemaker was localized to the high posterior septal region of the left ventricle underneath the mitral valve. This report describes in a man an idioventicular pacemaker that is innervated by sympathetic and vagal fibers and responsive to alterations in tone of both limbs of the autonomic nervous system. It offers the first clear proof that a ventricular pacemaker can be innervated and controlled by the vagus nerve and provides its location.

Effects of posture, Valsalva maneuver and respiration on atrial flutter rate: an effect mediated through cardiac volume.

The effects of passive upright tilting from 0 degrees to +60 degrees (n = 27), Valsalva maneuver (n = 16) and respiration (n = 10) on the rate of atrial flutter were studied in 27 patients. After tilting to +60 degrees, the atrial flutter cycle length shortened in all patients from 247.5 +/- 7 to 236.7 +/- 6.9 ms (range of shortening 1 to 21 ms, p less than 0.001). The Valsalva maneuver (strain of 40 mm Hg) shortened the flutter cycle length during the strain (phase 2) from 242.2 +/- 4.6 to 230.5 +/- 5 ms (range of shortening 2 to 19 ms, p less than 0.001). In 10 patients whose respiration was monitored, the flutter cycle length consistently prolonged during inspiration and shortened during expiration. Combined beta-adrenergic and muscarinic receptor blockade in six patients did not significantly alter the flutter cycle length at rest or the effects of the various maneuvers on the changes in flutter cycle length. This study revealed that the atrial flutter cycle length can be shortened by passive upright tilting, the strain phase of the Valsalva maneuver and expiration. Changes in flutter cycle length were independent of autonomic tone, implying that by decreasing cardiac volume, these maneuvers affect characteristics of the atrial flutter circuit, thereby producing dynamic changes in the rate of atrial flutter.

On-line epicardial mapping of intraoperative ventricular arrhythmias: initial clinical experience.

An on-line automatic mapping system was developed for beat by beat display of epicardial activation during ventricular tachycardia induced at the time of cardiac surgery. A sock array of 110 button electrodes was used to record and display local activation on a video monitor at 8.3 ms intervals. On instant replay in slow motion, epicardial pacing sites were accurately localized to the nearest electrode. Local unipolar electrograms were also recorded, first from the sock array, then from an array of 16 transmural needle electrodes. The epicardial display was verified by retrospective manually derived maps using the recorded epicardial electrograms. In four patients with coronary artery disease and recurrent inducible ventricular tachycardia, earliest epicardial activation was located on slow motion replay within 1 minute. Subendocardial sites of early activation were located within 10 minutes by replay of electrograms from the needle array before ventriculotomy. Transmural and endocardial resection of these sites prevented inducibility of the tachycardia on postoperative electrophysiologic study in three of the four patients. There has been no clinical recurrence of ventricular tachycardia after 3 to 14 months of follow-up despite cessation of antiarrhythmic therapy in three of the patients. This technique has unique advantages over existing mapping methods. It provides beat by beat display of activation sequences so that clinical tachycardias that are short in duration or pleomorphic in configuration now become amenable to mapping. In addition, it markedly shortens total time on cardiopulmonary bypass.

Autologous adrenal medullary transplant in progressive supranuclear palsy.

We transplanted autologous adrenal medullary cells to the caudate nucleus in 3 patients with progressive supranuclear palsy, using the method Madrazo has employed for neural transplantation in Parkinson's disease. Major and minor complications occurred post-operatively from which the patients recovered. One patient had a marked improvement in his postural stability and a decreased incidence of falling. This change was evident at 1 month after surgery and has remained for the 6 months of follow-up. Postural reflexes were not altered in the other 2 patients. There was no change in extraocular movements, speech, or the rigid-bradykinetic features of parkinsonism in any patient. Adrenal medullary transplantation has only limited efficacy in progressive supranuclear palsy.

Chronotropic effect of acetylstrophanthidin infusion into the canine sinus nodal artery.

Studies were performed to determine the chronotropic effect of acetylstrophanthidin during constant infusion through cannulation of the sinus nodal artery. Ten mongrel dogs weighing 13.5 to 18 kg were studied under sodium thiamylal anesthesia. Epicardial atrial and ventricular electrograms were recorded. The sinus nodal artery was cannulated and infused for 20 minutes at a rate of 2 cc/min with a solution containing acetylstrophanthidin, 0.5 microng/cc. Mean results for the group of 10 animals were determined. There was a gradual acceleration of the atrial rate of 45 beats/min after 6 to 8 minutes of infusion. The peak atrial rate of 175 beats/min was achieved by 10 to 12 minutes. This tachycardia persisted for 2 to 4 minutes without atrioventricular block or premature beats. By 12 to 14 minutes, there was a gradual slowing of atrial rate followed by bradycardia, sinus pauses and atrial arrest. Sinus nodal arterial infusion of acetylstrophanthidin produces an initial positive chronotropic effect and, if maintained, a depression of atrial rate and, terminally, atrial arrest. The gradual time course of development and decline of the tachycardia suggests that the "paroxysmal" atrial tachycardia caused by digitalis excess is the result of enhanced pacemaker automatically rather than reentry, and thus is not truly paroxysmal.

Management of intractable ventricular tachyarrhythmias after myocardial infarction.

Twenty-five patients with recent or old myocardial infarction were studied because they had life-threatening ventricular arrhythmias that required repeated cardioversions and were intractable to medical management. All patients had had a large anterior infarction a mean of 4.6 weeks before the emergence of the arrhythmias and all had severe left ventricular dysfunction. Cardiac catheterization or autopsy revealed a left ventricular aneurysm in 18 of 18 patients and obstruction of the left anterior descending coronary artery in 20 of 20 patients. Of 16 patients treated surgically with aneurysm resection or coronary bypass grafting, or both, 10 (62 percent) were alive after 3 to 39 (mean 26) months of follow-up. The perioperative mortality rate was 31 percent and only one patient died during the postoperative follow-up period 4 months after discharge from the hospital. By contrast, all nine medically treated patients died either in the hospital (four patients) or suddenly within 2 months of discharge (five patients). Ventricular fibrillation was documented as the cause of death in five of these patients. Surgical intervention was found to improve significantly the survival of these patients (P less than 0.02). The perioperative mortality rate was lower when at least 4 weeks had elapsed from acute infarction to surgery (10 versus 67 percent) and when the procedure included coronary bypass grafting (13 versus 50 percent), although these differences were not statistically significant (P greater than 0.05).

Isoproterenol induction of vasodepressor-type reaction in vasodepressor-prone persons.

The ability of isoproterenol to induce symptoms and laboratory findings of a vasodepressor reaction was tested in 48 patients, ages 17 to 74, divided into 4 groups according to the reason for their referral. Group 1 comprised 12 patients with vasodepressor syncope, group 2 had 8 patients with syncope of unknown origin, group 3 included 11 patients with syncope due to seizures in 2 and ventricular tachycardia in 9, group 4 had 17 patients with various arrhythmias not associated with syncope. Isoproterenol boluses were administered starting at 2 micrograms and increased in 2-micrograms steps to a maximum of 8 micrograms at 0 degree and +60 degrees. The responses at 0 degrees were all normal. At +60 degrees a vasodepressor reaction consisting of syncope or near syncope, hypotension and bradycardia was produced by isoproterenol (mean dose 6.0 +/- 0.26 micrograms) in 8 patients from group 1 (66.6%), 4 from group 2 (50%), 0 from group 3 and 4 from group 4 (23.5%). Three of the 4 patients in group 4 had a remote history of classic vasodepressor syncope. The overall sensitivity and specificity of the test were 73 and 85%, respectively, while the predictive accuracy of a test with positive or negative outcome were 69 and 89%, respectively. Muscarinic receptor blockade with atropine in 4 patients prevented isoproterenol-induced bradycardia but not hypotension or symptoms of fainting. Beta-adrenergic receptor blockade with propranolol inhibited all aspects of the isoproterenol-induced faint. Thus, the administration of isoproterenol during a passive upright tilt may identify persons who suffer from or are prone to a vasodepressor reaction.

Reflex mechanisms responsible for early spontaneous termination of paroxysmal supraventricular tachycardia.

The incidence and possible mechanism of early spontaneous termination of paroxysmal supraventricular tachycardia was studied in 20 consecutive patients. Episodes of induced tachycardia that terminated spontaneously within the 1st minute after initiation were included. Tachycardias ending spontaneously were associated with a reproducible course of hypotension at the onset followed by blood pressure recovery above control levels and termination. Spontaneous termination of tachycardias occurred within the A-V node 18 to 45 seconds (mean +/- standard error of the mean 27.9 +/- 5.3) after their onset. In the supine position (0 degrees) 9 (45 percent) of 20 patients showed spontaneous termination in 36 (16 percent) of 219 episodes of tachycardia. In the head-dependent position (-20 degrees) only 1 (8 percent) of 13 patients manifested spontaneous termination in 2 (4 percent) of 54 episodes. In the head up position (+60 degrees) only 1 (6 percent) of 18 patients exhibited termination in 2 (2 percent) of 102 episodes. After partial cholinergic blockade with intravenous hyoscine butylbromide, 20 mg, or atropine, 0.6 mg, none of five patients showed spontaneous termination in 25 episodes. After beta adrenergic blockade with 10 mg of propranolol intravenously, none of 16 patients showed spontaneous termination in 87 episodes of tachycardia. We conclude that the initial hypotension during tachycardia evokes a sympathetic response that increases blood pressure and this increase in turn causes a rise in vagal tone that breaks the tachycardia.

Vagal techniques for termination of paroxysmal supraventricular tachycardia.

Maneuvers that reflexly increase vagal tone were deployed to terminate the tachycardia in 68 consecutive patients with paroxysmal supraventricular tachycardia. The order and success rate of the protocol was as follows: 57 episodes were terminated with carotid sinus pressure alone or after pretreatment with edrophonium, 5 were terminated with the Valsalva maneuvers and 6 were terminated with phenylephrine. Potency testing showed that phenylephrine evoked the greatest increase in vagal tone. All cases demonstrated slowing of tachycardia ranging from 40 to 220 ms +/- standard error of the mean (mean 79.0 +/- 3.8 ms) followed by abrupt termination. Pauses after termination ranged from 900 to 3,300 ms (mean 1,683.8 +/- 66.6) with 54 patients showing pauses of 2,000 ms or less. Termination was highly reproducible showing an overall success of 148 (92 percent) of 160 trials among 22 selected cases. The extent of increased vagal tone needed to terminate paroxysmal supraventricular tachycardia was raised by augmented sympathetic tone (infusion of isoproterenol) and decreased by reduced sympathetic tone (pretreatment with propranolol). Thus, paroxysmal supraventricular tachycardia can be rapidly, safety and consistently terminated by maneuvers that reflexly increase vagal tone.

Use of telemetry functions in the assessment of implanted antitachycardia device efficacy.

Twenty patients (aged 50 +/- 21 years and mean left ventricular ejection fraction 37 +/- 17%) with recurrent ventricular arrhythmias were treated with an investigational, implantable combined antitachycardia-pacing cardioverter defibrillator. The device's telemetry capabilities include both stored (1-second snapshots) and real-time display of endocardial and device-circuit signals. The device can store these before, during and after up to 50 tachycardia and antitachycardia pacing episodes. All stored events are indexed to a 24-hour internal clock. During 10.1 +/- 5.1 months of follow-up, the device was used in 11 of 20 patients. In the entire group, antitachycardia pacing was activated on 44 +/- 14 occasions per patient (total 874) and shock delivery occurred on 8 +/- 14 occasions per patient (total 156). Reconstruction by stored telemetry of all device-therapy episodes was possible. Twenty-six percent of all shocks delivered were not appropriate and were due to atrial arrhythmias in 2 patients and dysfunction of the sensing lead in 3. The absence of a relation between symptoms and appropriate shock delivery was documented in 1 patient. Antitachycardia pace acceleration occurred in 5.3% of cases; 7% of attempts at pacing were unsuccessful and needed shock therapy. It is concluded that the enhanced telemetry available in newer antitachycardia devices enables more accurate assessment of device use and enhances diagnosis of inappropriate therapy delivery.

Testicular atrophy in AIDS: a study of 57 autopsy cases.

The pertinent clinical data and histologic features of the testes in 57 autopsied acquired immunodeficiency syndrome (AIDS) patients were analyzed and compared with those of 55 age-matched control patients without AIDS. The testes of the AIDS patients showed a significantly lower degree of spermatogenesis (determined by a testicular score count), as well as more prominent thickening of the basement membrane and interstitial fibrosis when compared with the controls. While the precise cause of testicular atrophy in AIDS patients remains to be determined, the chronicity of the disease, prolonged fever, malnutrition, testicular infection, and chemotherapy are all contributing factors. Since the vast majority of the studied AIDS patients were homosexual and most control patients were heterosexual, the observed testicular changes can be ascribed to AIDS and/or homosexuality. Because of a high prevalence of sexually transmitted diseases, antisperm antibodies, and possible zinc deficiency and endocrine disorders, homosexual men appear predisposed to tubular atrophy. Conversely, AIDS-related factors, such as a direct toxic effect of the human immunodeficiency virus on germinal epithelium or as yet undetermined endocrine imbalances might exert a detrimental effect on the testis independent of homosexuality.

Testicular atrophy in homosexual AIDS patients: an immune-mediated phenomenon?

An immunopathologic analysis of the testes of 20 homosexual acquired immune deficiency syndrome (AIDS) patients was performed to investigate the hypothesis that the testicular atrophy of these patients represents an immune-mediated process. The findings were compared to those in a control group of heterosexual men without AIDS. The testes of the homosexual AIDS patients showed an overall lower degree of spermatogenesis with more prominent interstitial inflammation and thickening of the tubular basement membrane. However, direct immunofluorescence and immunoperoxidase studies failed to demonstrate significant differences in the prevalence of immune complex deposits along the tubular basement membrane in the two study groups. No electron-dense deposits were demonstrated in cases examined ultrastructurally. Therefore, this study does not support the hypothesis that the testicular atrophy of homosexual AIDS patients is a manifestation of autoimmune orchitis. Further studies are needed to elucidate the pathogenesis of the testicular atrophy in AIDS, as this appears to be a specific manifestation of the disease.

Malignant lymphoma of the heart in acquired immune deficiency syndrome.

Malignant lymphoma of the heart was found at autopsy of two homosexual men with acquired immune deficiency syndrome (AIDS). Both patients had symptoms and signs of cardiac dysfunction, and it is likely that the immediate cause of their deaths was related to the cardiac tumors. In both cases, there was lymphomatous involvement of other organs, but the heart was the predominant site of disease. There was prominent endocardial and myocardial involvement, and both tumors were high grade large cell lymphomas with plasmacytoid features. In both instances, the lymphomas were diagnosed only at the autopsy, despite extensive antemortem cardiac evaluation in one patient. The clinicopathologic correlation, gross pathologic and histologic findings of the tumor, and their pattern and distribution suggest a de novo origin of the lymphoma in the heart in these two patients. Lymphomatous infiltration of the heart should be suspected in patients with AIDS who have cardiac symptoms.

Endobronchial irradiation with 192Ir in the treatment of malignant endobronchial obstruction.

From Jan 1, 1983 to April 30, 1989, 32 patients underwent 38 endobronchial treatments with 192Ir, bronchoscopically inserted for treatment of endobronchial obstructions secondary to bronchogenic carcinoma. Thirty-four of the 38 treatments were far enough apart to allow separate response analysis. Thirty of the 34 patients were symptomatically improved or stable; 22 of 24 patients who could be evaluated roentgenographically showed improved or stable chest roentgenograms, and ten of 12 patients evaluated bronchoscopically demonstrated improved patency of bronchial lumen.

Cardiac innervation after double lung transplantation. Toronto Lung Transplant Group.

Double lung transplantation has been successfully introduced for patients with end-stage pulmonary disease and preserved cardiac function. An advantage of this operation compared with heart-lung transplantation is retention of the recipient's heart. The operative dissection, however, may lead to interruption of sympathetic and parasympathetic pathways to the heart and consequent denervation of the native heart. The cardiac innervation of seven double lung transplant recipients was investigated by the heart rate response to carotid sinus massage, the Valsalva maneuver, intravenous injection of atropine, and exercise. Five single lung and two heart-lung transplant recipients were studied for comparison. Of the seven double lung transplant recipients, three had abnormal responses to carotid sinus massage, six to the strain phase of the Valsalva maneuver, and five to the release phase of the Valsalva maneuver. Three of six double lung transplant recipients tested had no response to intravenous injection of atropine, and five of seven patients had an abnormal recovery of heart rate after maximal exercise. No patient had a normal response to all interventions, and three patients had responses compatible with complete cardiac denervation. It is concluded that cardiac denervation may occur after double lung transplantation, most likely caused by surgical interruption of sympathetic and parasympathetic pathways during dissection of the recipient's trachea.

Concurrence of malignant and benign heterologous mixed tumors of the uterus.

A large polypoid uterine mas was composed to two distinct and separate parts: a malignant mixed müllerian tumor (MMMT) and a benign mixed mesenchymal tumor (BMMT). It was considered a collision of two neoplasms rather than a malignant degeneration of the BMMT. Malignant transformation of benign mesenchymal uterine tumors is a controversial concept which is difficult to prove or disprove. Concerning the histogenesis of MMMT it appears, at least in some cases, that they originate not from a single multipotential mullerian cell, but rather from two, a stromal cell and an epithelial cell. It is suggested furthermore, that in certain instances presence of one neoplastic component, e.g., adenocarcinoma, can incite proliferation of the second, sarcomatous element of the MMMT.

Intraperitoneal rupture of benign cystic ovarian teratoma.

Three patients are presented with the rare complication of intraperitoneal rupture of a benign cystic ovarian teratoma. Spillage of sebaceous material produces a chemical granulomatous peritonitis which may mimic the metastatic spread of ovarian carcinoma. The importance of a frozen-section examination prior to a definite procedure is stressed.

Coordinated micropinocytotic activity of adjacent neuronal membranes in mammalian central nervous system.

Neuropil from a number of sites in both mammalian and inframammalian species were examined by electron microscopy. Complex micropinocytotic invaginations in which a tongue of cytoplasm extended into the endocytotic indentation of the cell membrane, were observed in all tissues. These complex membrane infoldings occurred at both chemical and electrotonic synapses. Coated invaginations of apposed membranes, at which infoldings occurred directly opposite each other, were also observed at the interfaces between neighboring dendrites. These observations indicate that micropinocytotic membrane infoldings involving the coordinated activity of adjacent neuronal membranes occur in a wide variety of tissues. Coordinated exocytosis/endocytosis may provide a mechanism for interneuronal bulk transport of material, both at synapses and at non-synaptic sites, in the central nervous system.

Accuracy of self-reports of food intake.

Six boys reported their food intake with a surprising degree of accuracy, although they tended to overestimate at low levels and underestimate at high levels. Stimulated by this finding, the authors reviewed the literature and found six validated self-reports of food intake among adults and five among children. Most studies were small, but they reported similar findings. Because of the important policy implications, research is needed with larger and more representative samples to determine if self-reports of food intake are as accurate as they seem.