Vacuum phenomena in the sacroiliac joints and in association with sacral insufficiency fractures. Incidence and significance

STUDY DESIGN: The computed tomography scans of two groups of patients of similar age and sex, with and without sacral insufficiency fractures, respectively, were assessed retrospectively. OBJECTIVES: To determine the incidence of sacroiliac joint vacuum phenomena in individuals with and without sacral insufficiency fractures and to evaluate a possible association between vacuum phenomena and sacral insufficiency fractures. SUMMARY OF BACKGROUND DATA: The occurrence of vacuum phenomena is well recognized in the vertebra, but not in the sacroiliac joint. Gas foci in sacral insufficiency fractures recently has been reported. It has been suggested that the presence of vacuum phenomena may aid in the diagnosis of these fractures. METHODS: The computed tomography scans of 28 female patients with sacral insufficiency fractures and of 60 age- and sex-matched control individuals were evaluated. RESULTS: In the group with sacral insufficiency fractures, vacuum phenomena were detected in 69.2% of patients and in 63.5% of sacroiliac joints, with sacroiliac joint-related osteophytes found in 19.2% of patients. Very similar incidences were demonstrated in the control group. There was no correlation between sacroiliac joint osteophytes and vacuum phenomena in either group. The vacuum phenomenon was detected within the sacral insufficiency fracture in only one patient, in whom the fracture communicated with the adjacent sacroiliac joint. CONCLUSION: Vacuum phenomena are frequently found in the sacroiliac joints of elderly women, and their presence is of no diagnostic significance when demonstrated in patients with sacral insufficiency fractures.     

Spiroergometric evaluation of the effectiveness of treatment of cardiac insufficiency with cardiac glycosides

There were 29 patients with rheumatic heart disease and early stages of cardiac insufficiency under observation. Spiroergometry with the "Ergotest" device was conducted in dynamics to check whether the proper dose of the cardiac glycoside had been chosen. The results attest to the considerable improvement in the spiroergometric indices in patients with early stages of cardiac insufficiency who had been treated with digitalis. Spiroergometry yielded important additional criteria of the effectiveness of digitalization, particularly in individuals with normal or diminished rate of cardiac contractions.     

Effects of low doses of ionizing radiation and induced hypothyroidism on the course of pregnancy and the development of the offspring in rats

OBJECTIVES: To determine the appropriate indications and timing for surgery in children with either a perimembranous or a subarterial type of ventricular septal defect (VSD) associated with aortic cusp prolapse. DESIGN: Retrospective review of children with VSD and associated aortic cusp prolapse with or without aortic regurgitation. This review was based on data obtained from clinical findings, two-dimensional echocardiography, cardiac catheterization and angiocardiography. SETTING: Tertiary health care facility with two-dimensional and colour Doppler echocardiographic and cardiac surgery facilities, and a catheterization laboratory. PATIENTS: Forty-eight patients were found to have perimembranous or subarterial VSDs in association with aortic cusp prolapse with or without aortic regurgitation. INTERVENTIONS: All 48 patients had high resolution two-dimensional and colour Doppler echocardiography. Of the 19 patients who underwent surgical closure of their VSD, five also had an aortic valvuloplasty and one had an aortic valve replacement. Cardiac catheterization was performed in 16 of the 19 surgical patients and 12 of the 29 nonsurgical patients. MEASUREMENTS AND MAIN RESULTS: Annual clinical and echocardiographic assessments in the nonsurgical group did not demonstrate increasing aortic insufficiency. Two children in the nonsurgical group showed spontaneous resolution of aortic insufficiency. In the surgical group, four children with VSD and clinical aortic insufficiency had surgery at less than five years of age; two were found to be regurgitant-free, one had trivial clinical aortic insufficiency and the other had echocardiography-only insufficiency. Of the seven surgical patients older than five years with VSD and clinical aortic insufficiency, four were found to be regurgitant-free, one had echocardiography-only regurgitation and two were unchanged. Two children undergoing surgery with VSD and no aortic insufficiency had postoperative echocardiography-only regurgitation, presumably related to cusp deformity from presurgical prolapse. Children with large VSDs with or without aortic cusp prolapse required surgery for indications of shunt size and pulmonary resistance. CONCLUSIONS: For children with small perimembranous VSDs and cusp prolapse, surgery is indicated only if there is clinical evidence of aortic regurgitation and progressive left ventricular enlargement.     

Extracorporeal membrane oxygenator support for cardiopulmonary failure. Experience in 28 cases

We have used extracorporeal membrane oxygenation (ECMO) for 28 patients (14 children and 14 adults) over a 5 year period. Nine patients improved on ECMO and 5 were long-term survivors. ECMO was used for pulmonary insufficiency in 24 patients. Initially, only moribund patients were treated, but recently the combination of open lung biopsy and pulmonary insufficiency index (PII) has been used to select patients. The best results have been obtained in newborn cases and the adult capillary leak syndromes; the major problem has been progression to fibrosis despite ECMO support. ECMO was used for cardiac failure in 4 patients. Children with postoperative cardiac failure did the best; profound shock was not reversed with venoarterial bypass. ECMO support is lifesaving in selected cases of pulmonary insufficiency. Initial trials in cardiac failure and the infant age group in this series suggest that ECMO will have an even greater role in those applications.     

Treatment of fibrous dysplasia involving the proximal femur

Bone marrow transplant-associated thrombotic microangiopathy (BMT-TM), usually associated with thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and renal insufficiency, has been reported to occur approximately 5-6 months after BMT. We report a case of relapsed malignant lymphoma complicated by BMT-TM of hyperacute onset, which has never been described in the literature. Our patient, a 52-year-old male, developed MAHA with gross haematuria, thrombocytopenia, lactate dehydrogenase elevation and renal insufficiency 2 days after autologous PBSC transplantation following high-dose chemotherapy. Supportive treatment, ie glucocorticoid, fresh frozen plasma and haemodiafiltration were given, and thereafter the BMT-TM gradually improved. In heavily pretreated patients, caution should be exercised for possible occurrence of the BMT-TM of hyperacute onset.     

The efficacy of pneumocalorimetry for the quantitative evaluation of treatment results in patients with pneumoconiosis and rheumocarditis

The respiratory system conditioning function (CFRS) was evaluated with the aid of pneumocalorimetry by taking account of respiratory thermic losses spent to warm breathing air in the volume of vital capacity. There were 100 patients with pneumoconiosis and 49 ones with rheumatic carditis. In the course of treatment of patients with pneumoconiosis, both occurrence and degree of insufficiency of the conditioning function (CF) got decreased, with reduction in CF insufficiency degree being 60% in those patients faring well owing to the treatments administered, and 40% in those not having benefited much from the treatment. 73% of patients with rheumatic carditis experienced, under the influence of the treatment received, decline in the degree of CF insufficiency. Thus, pneumocalorimetric criterion described above will, we believe, help in quantitating the efficiency of treatment of CF insufficiency.     

Congenital malformations of the mitral valve in children. Pathology and surgical treatment

A systematic study of congenital mitral valve malformations was undertaken on a surgical basis in an attempt to develop techniques of valvular reconstruction adapted to the various lesions. Forty-seven children between the ages of 4 months and 12 years (average 6 years, 4 months) have been operated upon between January, 1970, and March, 1976. Valvular lesions were classified into four group: Group I, mitral insufficiency owing to valvular lesions: Group II mitral insufficiency with subvalvular lesions; Group III, mitral insufficiency and stenosis; Group IV, stenosis. Associated lesions (ventricular or atrial septal defects, coarctation, or aortic valve stenosis) were present in 31 patients (65 per cent) and were corrected during the same operation. Valve reconsruction was possible in 38 patients whereas valve replacement was necessary in 9 patients. In the valve repair group there were three operative deaths (8 per cent), no late deaths, one reoperation for residual ventricular septal defect, and one myocardial infarction. In the valve replacement group of 9 patients, there were three operative deaths, three late deaths, and one case of repeated embolization. Thirty-one of 38 patients in the valve repair group were classified into Functional Class I after the operation (86 per cent), 2 were in Class II, and one in Class III. Minimal or moderate regurgitation and cardiomegaly persisted in the majority of the patients. Pulmonary artery pressure significantly decreased, however, as demonstrated by postoperative catheterization in 17 patients.     

Incidence and morphology of carotid shudders in aortic valve disease

The incidence and morphology of shudders in carotid arterial pulse tracings were examined in 73 patients with aortic valve disease documented by cardiac catheterization. Two forms of carotid shudder were recorded: coarse and fine. Shudders were present in 67 per cent of patients with aortic stenosis, 48 per cent of patients with aortic insufficiency, and 57 per cent of patients with mixed aortic stenosis and insufficiency. No significant difference existed among these three groups of patients with respect to the over-all incidence of carotid shudders or with respect to the incidence of coarse or fine shudders. In patients with aortic insufficiency, stroke volume index (Fick) and phonocardiographic systolic ejection murmur amplitude were significantly greater (p less than 0.01, p less than 0.001, respectively) in those with coarse carotid shudders compared with those manifesting fine or absent shudders. Loud, flow-related, systolic ejection murmurs of aortic insufficiency are capable of producing radial vibrations in the aortic wall which are recorded as carotid shudders. The finding of a carotid shudder in a patient with aortic valve disease does not enable the physician to distinguish between stenosis, insufficiency, or mixed stenosis and insufficiency.     

MR appearance of parasymphseal insufficiency fractures of the os pubis

OBJECTIVE: To clarify the MRI features of parasymphyseal insufficiency fractures of the os pubis. DESIGN AND PATIENTS: MRI was performed in four postmenopausal women with parasymphyseal insufficiency fractures. The diagnosis was confirmed with plain films in every patient. T1-weighted and T2-weighted images were obtained in four patients using a 1.5-T unit. Postcontrast T1-weighted imaging was also done in three patients. RESULTS AND CONCLUSIONS: MRI of pubic parasymphyseal insufficiency fracture characteristically demonstrates a hyperintense mass lesion with a hypointense rim on T2-weighted imaging, showing peripheral and septal enhancement after contrast administration. It is important to have this entity in mind in patients with osteoporosis, especially in patients with a history of pelvic irradiation for malignant disease, so as not to misinterpret it as a chondroid tumor or bone metastasis.     

A further look at tricuspid annuloplasty

Is it necessary to replace the tricuspid valve or insert a tricuspid ring for pure tricuspid insufficiency, or is repair satisfactory? In 96 of 113 patients with pure tricuspid insufficiency the tricuspid valve was repaired by converting the incompetent three-leaflet valve into a two-leaflet one. To avoid liver damage in these critically ill patients, the inferior caval tie was omitted during the open-heart procedure. There have been 5 deaths in the last 51 consecutive operations. Three patients developed recurrent tricuspid insufficiency secondary to failure of the mitral repair or replacement. It is concluded that tricuspid repair for pure tricuspid insufficiency is a simple and excellent method for treating severe, pure tricuspid insufficiency.     

Validity of cardiac output measurement by the thermodilution method in the presence of acute tricuspid regurgitation

Evaluation of patients with acute tricuspid insufficiency may include assessment of cardiac output by the thermodilution method. The accuracy of estimates of thermodilution-derived cardiac output in the presence of tricuspid insufficiency has been questioned. This study was designed to determine the validity of the thermodilution technique in a canine model of acute reversible tricuspid insufficiency. Cardiac output as measured by thermodilution and electromagnetic flowmeter was compared at two grades of regurgitation. The relationship between these two methods (thermodilution/electromagnetic) changed significantly from a regression slope of 1.01 +/- 0.18 (mean +/- standard deviation) during control conditions to a slope of 0.86 +/- 0.23 (p < 0.02) during severe regurgitation. No significant change was observed between control and mild regurgitation or between the initial control value and a control measurement repeated after tricuspid insufficiency was reversed at the termination of the study. This study shows that in a canine model of severe acute tricuspid regurgitation the thermodilution method underestimates cardiac output by an amount that is proportional to the level of cardiac output and to the grade of regurgitation.     

Clinical evaluation of bone-densitometry in patients with final renal insufficiency operated for hyperparathyroidism

Because of difficulties in evaluating bone mineral mass with conventional methods in patients with final renal insufficiency before and after parathyroidectomy, bone densitometry has been tried. During a three year period ten patients have been selected for surgery. The parathyroidectomy performed was total in nine patients and subtotal in one. Bone mineral mass was significantly lower preoperatively in the operated patients than in other patients on regular hemodialysis and also lower than in a normal material. In four of ten patients there was a transient decrease in bone mineral mass after parathyroidectomy. Thereafter there was a significant increase in five of ten patients and in the whole group of patients. Thus bone densitometry was found to be of value in following patients with renal insufficiency selected for parathyroidectomy.     

Effect of cardiac dysrhythmia on cerebral perfusion

Extracranial carotid arterial obstructive disease has been the entity most commonly associated with transient cerebrovascular insufficiency. A nonobstructive, frequently overlooked cause of cerebral ischemia is cardiac dysrhythmia. We have explored this by observations of experimental animals and of man. Blood flow and pressure in the carotid arteries of dogs were shown to be decreased by mechnically induced premature ventricular contractions. The significance of the cardiogenic contribution to altered cerebrovascular perfusion was studied by ocular and brachial plethysmography in 210 patients suspected by history of having carotid arterial insufficiency. Of the 210 patients, 62 demonstrated abnormal ocular plethysmographic recordings, and of those, nine had dysrhythmias associated with significant deficits of ocular perfusion. Five patients whose recordings were technically suitable for publication are presented to demonstrate the bizarre ocular plethysmographic recordings seen during the dysrhythmic cycle.     

Determination of the myocardial reserve by ergometry

An analysis has been made of the data of direct and indirect methods for evaluation of myocardial reserve and occult cardiac insufficiency in varying groups of patients with postinfarction cardiosclerosis and hypertensive disease. Absolute and relative values of the systolic AD, cardiac contraction rate and ECG data have been studied. A combined characteristics of the hyposystolic type reaction and the scheme for the examination of patients are presented.     

Free-water clearance and the early recognition of acute renal insufficiency after cardiopulmonary bypass

The predictive value of free-water clearance measurements for the early recognition of acute renal insufficiency was evaluated in 59 patients immediately following cardiopulmonary bypass. Blood urea nitrogen and serum creatinine measurements were taken before and after operation. Intraoperatively, immediately after completion of bypass, urine and serum samples were obtained for osmolality. Duration of bypass, urine output, degree of hemolysis, and quality of perfusion were recorded. Fifty-four patients developed no signs of renal insufficiency following bypass, and all had free-water clearance values equal to or less than -20 ml per hour. Five patients who had free-water clearance values equal to greater than -8 ml per hour developed manifestations of an acute renal insufficiency state. There were no false-negative or false-positive determinations. Consequently, free-water clearance measurements appear to be a reliable indicator of those patients who will develop renal insufficiency following cardiopulmonary bypass. Early recognition provides an opportunity immediately after operation for initiating treatment consisting of administration of diuretics, potassium restriction, and oliguric fluid regimens.     

Gadolinium-based contrast and carbon dioxide angiography to evaluate renal transplants for vascular causes of renal insufficiency and accelerated hypertension

PURPOSE: To evaluate the utility and potential nephrotoxicity of gadolinium-based contrast angiography when used with carbon dioxide angiography in renal transplant patients with suspected vascular causes of renal insufficiency and/or accelerated hypertension. MATERIALS AND METHODS: Thirteen consecutive renal transplant patients with suspected vascular causes of renal insufficiency and/or accelerated hypertension were evaluated with gadolinium-based contrast and CO2 angiography with use of digital subtraction techniques. Stenotic lesions were treated with angioplasty with/or without stent placement. No iodinated contrast agents were used. Serum creatinine levels were obtained before and at 24 and 48 hours after the procedure. An increase in creatinine levels greater than 0.5 mg/dL (44 micromol/L) was considered significant. RESULTS: Nine patients were studied for renal insufficiency, two for accelerated hypertension, and two for both. All 13 studies were considered diagnostic. Significant stenoses were treated in four patients with angioplasty with or without stent placement. Two patients had progression of their renal insufficiency. One of these patients underwent biopsy and was found to have both acute and chronic rejection. The other patient underwent cardiac catheterization 2 days after a transplant renal artery angioplasty. In the remaining nine patients with renal insufficiency (creatinine range, 1.8-3.9 mg/dL [159-345 micromol/L]; mean, 2.7 mg/dL [239 micromol/L]), renal function improved or did not worsen. CONCLUSION: Based on this limited study, gadolinium-based contrast angiography appears to be a promising supplement to CO2 angiography for the diagnosis and treatment of vascular lesions in patients with renal transplant insufficiency and/or accelerated hypertension. Further study is necessary to determine safety, optimal gadolinium dosage, and imaging parameters.     

A phase II trial of interleukin-2 and interferon-alpha in the treatment of metastatic colorectal carcinoma

A total of 29 patients with stage IV colorectal cancer were entered into a phase II trial of bolus interleukin-2 (IL-2) and interferon-alpha (IFN alpha) (3 x 10(6) U/m2 of each cytokine given i.v. q8h x 15 doses and repeated in 2 weeks). Immunologic parameters measured on isolated peripheral blood lymphocytes revealed increased activated T cells with upregulated natural killer and lymphokine-activated killer activity. Among 24 evaluable patients, there were 4 partial responses (17%) of short duration ( < or = 6 months). Three of the responding patients had been refractory to prior chemotherapy. Overall median survival in the 24 evaluable patients was 18.5 months. Therapy necessitated an inpatient setting, with the most common toxicities being hypotension, hepatic insufficiency, fever, hypocalcemia, nausea/vomiting, and renal insufficiency. There were two treatment-related deaths. Because neither IL-2 nor IFN alpha alone has significant activity against colorectal cancer, the responses observed in this study suggest a potential synergistic effect between the two cytokines. However, the toxicity and short duration of response without survival benefit do not support the routine use of this regimen as a therapeutic modality for this tumor histology.     

The renal factor in the post-traumatic "fluid overload" syndrome

Hypervolemia with hypertension often occurs 36-72 hours following massive blood and fluid replacement for hypovolemic shock. This syndrome of "fluid overload" has been attributed to the rapid intravascular flux of previously sequestered fluid in patients with impaired diuresis. This hypothesis was tested in 35 injured patients who received a mean of 9.3 L of blood and 17.4 L of salt during resucitation. The renal parameters measured soon after resuscitation included: 1) renal clearance of inulin (GFR), para-amino hippurate (ERPF), milliosmoles, sodium, and free water; 2) inulin space, renal vascular resistance (RVR), O2 consumption, renin, renal blood flow (RBF), and response to furosemide. Eighteen patients developed hypertension, hypervolemia, and respiratory insufficiency. When compared to the 17 normovolemic, non-hypertensive patients, the 18 hypervolemic patients had significantly increased RVR, with a significant decrease in RBF despite an increase in plasma volume and cardiac output. Furosemide produced less diuresis and natriuresis in the hypertensive patients. The balance between hypovolemia and "fluid overload" seemed percarious in the hypertensive patients. Peripheral renin and catecholamine levels were normal in both groups. Patients with post-traumatic "fluid overload" appear to have a combination of hypervolemia, respiratory insufficiency, hypertension, increased cardiac output, decreased extracellular fluid space, and decreased renal perfusion. These findings suggest that decreased interstitial fluid space compliance rather than "fluid overload" is the underlying factor leading to respiratory insufficiency. The therapeutic aspects of these findings are discussed.     

The safety and efficacy of transcatheter arterial chemoembolization in the treatment of patients with hepatocellular carcinoma and main portal vein obstruction. A prospective controlled study

BACKGROUND: Transcatheter arterial chemoembolization (TACE) has been contra-indicated for the treatment of patients with hepatocellular carcinoma (HCC) and main portal vein (MPV) obstruction because of the potential risk of hepatic insufficiency resulting from ischemia after TACE. The current controlled study was undertaken to assess the safety, efficacy, and predictive factors of favorable response to TACE in patients with HCC and MPV obstruction with good hepatic function and adequate collateral circulation around the MPV. METHODS: Of a total of 47 patients, 31 were treated with TACE, and 16 who declined the procedures were untreated controls. Thirty-six patients (77%) had diffuse-type HCC and 11 (23%) had nodular-type HCC. During the first week after TACE immediate postprocedural complications were evaluated, and the development of hepatic insufficiency as a late complication was assessed at the end of the fourth week. The cumulative survival rate was estimated by the Kaplan-Meier method, and predictors of better prognosis were obtained by univariate and multivariate analyses. RESULTS: Although no patients showed clinical evidence of hepatic insufficiency as an immediate complication, transient fever and abdominal pain were common. Progressive hepatic insufficiency developed at the fourth week; however, there was no difference between the treated and untreated groups. The survival time of treated patients was statistically no longer than that of untreated patients. In the univariate analysis, tumor type and size, the pattern of iodized oil uptake in the tumor, and the presence of iodized oil uptake in the tumor thrombi at the MPV significantly influenced the prognosis. Tumor type, whether treated or not, was the most important prognostic factor patients with nodular-type HCC had significantly longer survival time (median, 11 months) than those with diffuse-type HCC (median, 4 months). Regarding the efficacy of TACE, there was no statistical difference in survival between treated and untreated diffuse-type HCC patients. In comparison, with nodular-type HCC it seemed that survival time was longer for TACE-treated patients (median, 30 months) than for untreated patients (median, 7 months). CONCLUSIONS: TACE may be a safe modality for the treatment of patients with HCC and MPV obstruction, provided that the patients have good hepatic function and collateral circulation around the MPV. However, TACE was not efficacious in the treatment of diffuse-type HCC. The authors recommend TACE for treating nodular-type HCC because of the potential benefit of prolonged survival.     

Functional and metabolic evaluation of the hypertrophied heart using MRI and 31P-MRS

Most patients with cystic fibrosis require oral administration of pancreatic enzymes to treat pancreatic insufficiency. Recent use of higher-strength enzyme preparations in large doses has been found to be associated with fibrotic strictures of the colon. We report a case of pancolonic fibrosis due to pancreatic enzyme use.