Changes of endothelin-1 and atrial natriuretic peptide during dobutamine stress echocardiography

The aim of this study was to test the hypothesis that plasma endothelin-1 (ET-1) and atrial natriuretic peptide (ANP) concentrations in patients with ischemic heart disease are related either to myocardial ischemia or left ventricular (LV) dysfunction during dobutamine stress echocardiography. Plasma concentrations of ET-1 and ANP were measured in three patient groups. Group I (n = 21) patients had normal stress echocardiography and a resting LV ejection fraction (LVEF) of 40% or more. Group II (n = 32) had positive stress echocardiography and a resting LVEF of more than 40%. Group III (n = 18) had positive stress echocardiography with a resting LVEF of less than 40%. All three groups were subjected to thallium 201 scintigraphy and coronary angiography studies. The resting LV end-diastolic pressure was significantly higher in groups II and III than in Group I. The LVEF decreased significantly in group III compared to groups I and II. In the resting state, groups II and III had higher ET-1 concentrations than Group I (p = 0.021 and p = 0.039, respectively). The plasma ANP concentration was higher in group III than in groups I and II (p = 0.005 and p = 0.054, respectively). During peak dobutamine infusion, the ET-1 concentration dropped 8.7% from the baseline in group I, 10.2% in group II, and 10.5% in group III. The ANP concentrations were increased in all three groups but only the increase in Group II reached statistical significance. In conclusion, in patients with suspected ischemic heart disease, the concentrations of ET-1 and ANP may predict significant anatomic and functional coronary artery disease. However, ET-1 does not play a pathophysiologic role during an ischemic attack.     

Prospective study of risk factors in natural rubber latex hypersensitivity

Five hundred sixty-nine subjects routinely underwent skin prick tests for latent sensitization to latex. The study of risk factors included skin tests to inhalant allergens, to diagnose atopy, and a questionnaire aimed at revealing frequent exposure to latex such as the wearing of gloves, multiple surgical procedures, or urinary catheterization. The subjects were categorized into five groups: group I, subjects with no risk factor (n = 272); group II, nonatopic subjects exposed to latex (n = 73); group III, atopic subjects not exposed (n = 180); group IV, exposed atopic subjects (n = 44); and group V, subjects with a history of intraoperative anaphylactic shock caused by latex (n = 13). Twenty-five subjects had spina bifida and were in either group II (14 subjects) or group IV (11 subjects). The questionnaire identified a probable allergy to latex in 18 subjects: 16 cases were confirmed by skin test, but responses were not informative in 23 patients who were sensitive to latex. Positive prick tests to latex were obtained in 0.37% of group I, 6.85% of group II, 9.44% of group III, and 36.36% of group IV. Of the children with spina bifida, 32% had positive skin test results. As risk factors, atopy and exposure were synergistic. We recommend predictive prick tests not only in children with spina bifida but also in any atopic subject or in any patient with a history of frequent exposure to latex. Latex could be considered a habitual allergen. The use of latex urinary catheters should be avoided in patients who are catheterized on a daily basis.     

Cytotoxicity of sera from rats with puromycin aminonucleoside nephrosis

BACKGROUND: Sensitization to allergens has been shown to be a risk factor for adults with acute asthma first seen in the emergency department. OBJECTIVE: The purpose of this study was to evaluate the prevalence of specific IgE to common aeroallergens in children with asthma first seen in the emergency department and in control subjects. METHODS: Fifty-four children, aged 3 to 16 years (mean age, 8.34 years) who visited the emergency department for treatment of acute bronchospasm or other illness, were evaluated. Specific IgE to seven common aeroallergens and four common storage mites was determined. Group I consisted of 29 patients who had acute bronchospasm and histories of recurrent asthma. Group II consisted of 25 control subjects who had no clinical history of atopic disease. Group I and II were compared for differences in the prevalence of positive RAST responses to the 11 allergens tested. Dust samples were collected from 17 homes of subjects in group I and from 13 homes of subjects in group II and were analyzed for levels of Der p 1 and Der f 1. RESULTS: Statistically significant differences in the prevalence of positive RAST results between groups I and II were found in response to: Dermatophagoides pteronyssinus, 89.6% versus 36% (p = 0.0001); Blattella germanica, 45.8% versus 9.5% (p = 0.018); Alternaria tenuis, 44.8% versus 4% (p = 0.001); and the storage mites Aleuroglyphus ovatus, 39.2% versus 4% (p = 0.002); Blomia tropicalis, 42.8% versus 0% (p = 0.0002); Chortoglyphus arcuatus, 46.4% versus 0% (p = 0.0001); and Lepidoglyphus destructor, 32.1% versus 0% (p = 0.0019). Mean specific IgE levels, expressed as percent of the total counts bound, were significantly higher in group I compared with group II only in response to D. pteronyssinus, 21.9% versus 2.1% (mean percent of total counts bound) (p = 0.0001). Analysis of dust samples revealed no significant differences between the two groups, except for a higher concentration of Der f 1 in the sofas of subjects in group II. CONCLUSION: Sensitization to D. pteronyssinus, storage mites, and, to a lesser extent, to A. tenuis and B. germanica is associated with acute childhood asthma that requires emergency treatment in Florida.     

Celtic ancestry, HLA phenotype and increased risk of skin cancer

Individuals of Celtic ancestry are claimed to be at greater risk of skin cancer than non-Celts, and various positive and negative associations between certain human leucocyte antigen (HLA) phenotypes and the development of skin cancer have been described. The aims of this study were to determine whether any HLA phenotypes are associated either with Celtic or non-Celtic ancestry, or skin type. One thousand and ten members of the Welsh Bone Marrow Donor Registry (WBMDR), whose HLA phenotypes are known, were asked to complete a questionnaire which enquired as to their family origins and their 'Index of Celtic Ancestry' scored out of 12. Three groups were identified: non-Celts (score < 3), Celts (score > 9), and a subset of the Celts--'high scoring' Celts (score > 10). Details of hair and eye colour and skin type were also requested. Skin type and HLA-A, -B, -DR and -DQ frequencies were compared between the three groups (Celts, non-Celts and 'high scoring' Celts), and a random indigenous population of 9196 members of the WBMDR. Seven hundred and thirty-six replies were received (279 male, 457 female, mean age 31 years). One hundred and forty-four Celts, 51 'high scoring' Celts and 170 non-Celts were identified. Forty-six (32%) Celts had skin type I or II compared with 36 (21%) non-Celts (P = 0.039), and 37 (73%) 'high scoring' Celts had skin type I or II (P < 0.0001). However, there were no significant differences between the groups with regard to hair colour, eye colour or number of episodes of painful sunburn. The frequency of HLA-DR4 was 32% in the non-Celtic group, 44% in the Celtic group (not significant), and 53% in the 'high scoring' Celts (P = 0.008). However, the difference was not significant after correction. There were no significant associations between skin type and HLA phenotype. HLA-DR4 is known to be associated with an increased risk of both basal cell carcinoma and malignant melanoma and its increased frequency in Celts may be an independent risk factor for skin cancer in addition to skin type.     

Prognostic significance of silent myocardial ischaemia during maximal exercise testing after a first acute myocardial infarction

Clinical, exercise, and angiographic variables, and long-term follow-up were compared in patients, who, during maximal Bruce exercise testing after a first acute myocardial infarction (AMI), had positive responses to exercise testing (n = 116, 38% of 303) with (n = 23, group I) or without (n = 93, group II) angina. Group I patients more often (52 vs 19%, P < 0.001) had a history of pre-infarction angina. Group II had a greater proportion (75 vs 52%, P < 0.05) of inferior wall AMI, whereas group I had a greater proportion (30 vs 19%, P < 0.01) of non-Q wave AMI. Total exercise duration was significantly (P < 0.01) longer in group II (7.6 +/- 3.2 vs 5.5 +/- 3.1 min). Maximal exercise heart rate (144 +/- 22 vs 133 +/- 21, beats.min-1 P < 0.05) was also higher in group II. A greater proportion of group II patients (37 vs 9%, P < 0.05) had single-vessel disease, whereas multivessel disease was more common (91 vs 63%, P < 0.03) in group I. Left ventricular function was similar in both groups. During follow-up (48 +/- 22 months) the incidence of cardiac death (group I, 3.3%, group II, 4.8%), of recurrent infarction (group I, 4.8%, group II 3.3%), and of revascularization procedures (group I, 28.5%, group II, 19.8%) were similar in both groups. Although asymptomatic exercise-induced ischaemia was associated with better exercise performance and less extensive coronary disease than symptomatic ischaemia, it had the same long-term prognostic implications.     

Influence of long-term recombinant human erythropoietin (rHuEpo) therapy on plasma leptin and neuropeptide Y concentration in haemodialysed uraemic patients

Of 98 retrospectively selected patient couples insured under one scheme (group I) who, based on performance of a hysterosalpingogram (HSG), were assumed to be under active infertility care, 96 were confirmed as infertile. These were matched by date, patient age and time of HSG to 96 patients under infertility care (group II). Both patient populations were then prospectively evaluated for outcome and cost of treatment. Total physician charges for groups I and II were similar. However, charges per achieved clinical pregnancy were higher in group I than group II since group I patients demonstrated a lower pregnancy rate (28/96, 29%) than group II patients (41/96, 43%) (P=0.05). Within group I, pregnancy rates were identical, whether treatment was provided by generalists or subspecialists. In group II, all care was provided by specialists. The number of days of treatment did not vary between groups I and H, though generalists in group I provided significantly fewer treatment days than specialists in either group I (P=0.003) or in group II (P=0.021). This was primarily due to a significantly higher patient drop-out rate in group I patients, and especially amongst those who received care from generalists (P < 0.0019). Group I patients also encountered significantly more surgical procedures than group H patients (P=0.0016). If physician charges are discounted and customary surgical facility costs are added, the actual cost structure for fertility care in group I patients was dramatically higher than in group II patients. The most cost-effective format to provide infertility care of high quality appears to be a managed care setting in which subspecialists provide a majority of care and in which patient choice is restricted to those subspecialists.     

Aprotinin and deep hypothermic circulatory arrest: there are no benefits even when appropriate amounts of heparin are given

OBJECTIVE: To evaluate retrospectively the effect of 'high-dose' aprotinin on blood losses, donor blood requirements and morbid events on patients undergoing ascending aorta and/or aortic arch procedures with the employ of deep hypothermic circulatory arrest (HCA). METHODS: During the period 1987-1994, 39 patients underwent a thoracic aorta procedure with the employ of circulatory arrest; of these 18 (46.2%) were operated on during the period 1990-1994 and were given aprotinin intraoperatively following the 'high-dose' protocol (group I), while 21 (53.8%) who underwent surgery during the years 1987-1989, did not receive intraoperative aprotinin and served as historical controls (group II). Twenty-seven (69.2%) patients were male, 18 (46.2%) were operated on on an emergency basis, 15 (38.5%) were acute type A dissections, and two (5.1%) were redo-operations. Circulatory arrest times were not significantly different between the two groups (40 +/- 4 (S.E.) group I vs. 43 +/- 4 min group II, P = 0.62) likewise cardiopulmonary bypass (CPB) times (181 +/- 9 vs. 201 +/- 20 mm, P = 0.74) and the amount of heparin administered (32056 +/- 1435 vs. 31 691 +/- 1935 IU, P = 0.56). RESULTS: Postoperative blood loss was comparable between the two groups (1213 +/- 243 (median 850) group I vs. 1528 +/- 377 (median 880) ml group II, P = 0.87), as well as the number of units of donor blood transfused (9.4 +/- 3.0 (median 6) vs. 9.9 +/- 3.6, (median 5) P = 0.87), and revisions for bleeding (2/18, 11.1% vs. 3/21, 14.3%, P = 0.77). In-hospital mortality rate was not statistically different (5/18, 27.7% group I vs. 6/21, 28.6% group II, P = 0.92). There were no significant differences between the two groups in myocardial infarction (2/18, 11.1% vs. 0/21, 0%, P = 0.21), and postoperative renal failure rates (3/18, 16.7% vs. 2/21, 9.5%, P = 0.65). On the other hand, there was a trend towards an increased incidence of permanent neurological deficit (5/18, 27.7% group I vs. 1/21, 4.8% group II, P = 0.07) and towards a more complicated postoperative course (perioperative renal failure and/or myocardial infarction and/or neurological deficit either transient or permanent) (8/18, 44.4% group I vs. 4/21, 19% group II, P = 0.09) in group I patients. Forward stepwise logistic regression analysis, performed on the whole group of patients, identified chronic obstructive pulmonary disease (P = 0.010, Odds ratio (OR) = 5.7), aprotinin use (P = 0.017, OR = 5.1), and the number of units of blood collected intraoperatively by the cellsaver (P = 0.045, OR = 1.3/unit) as independent predictors of complicated postoperative course in the whole group of patients. CPB time (P = 0.040, OR = 1.032/min), circulatory arrest time (P = 0.053, OR = 1.22/min), and overall donor blood units transfused (P = 0.067, OR = 1.37/unit) emerged as independent risk factors for in-hospital mortality at multivariate analysis. CONCLUSIONS: Even when appropriate amounts of heparin are administered, 'high-dose' aprotinin probably is not an effective blood-sparing drug in deep HCA. Aprotinin should be employed cautiously in this clinical setting because of its possible correlation with an increased rate of postoperative morbid events.     

Spread of spinal anaesthesia for caesarean section in singleton and twin pregnancies

We have compared the spread of spinal anaesthesia in parturients with singleton and those with twin pregnancies. Fifty-five unpremedicated patients with uncomplicated pregnancy scheduled for Caesarean section were allocated to two groups: group I = 35 singleton mothers; group II = 20 with twin pregnancy. Both groups received spinal anaesthesia with hyperbaric bupivacaine 10 mg (2 ml of 0.5%). Mean birthweight was 3290 (SD 452) g and 5008 (495) g in groups I and II (combined birthweights), respectively. We found a statistically significant difference in onset and maximal cephalad spread of spinal anaesthesia (group I median T5, range T8-T4; group II T3, range T6-T2). The mechanisms of higher cephalad spread of spinal anaesthesia in parturients may be a decrease in cerebrospinal fluid volume secondary to shunting of blood from the obstructed inferior vena cava to the extradural venous plexus and increased nerve sensitivity to local anaesthetics because of increased concentrations of progesterone. The twin pregnancy group had heavier, larger uteri and greater daily production of progesterone.     

Serum levels of eosinophil cationic protein and eosinophil protein x in pollen atopic patients with stable asthma and its relation with bronchial hyperresponsiveness

Eosinophils are important effector cells in allergic inflammation described in allergic rhinitis (AR) and allergic bronchial asthma (BA). During the pollen season serum levels of eosinophil cationic protein (ECP) and eosinophil X protein/eosinophil-derived neurotoxin (EPX/EDN) are increased in BA. The aim of the present study was to evaluate the serum levels of ECP and EPC in pollen atopic patients with AR and BA during the winter. 92 patients were studied. They were divided into three groups: I 29 patients with AR, II 51 patients with BA and III 12 healthy subjects. Allergic rhinitis and bronchial asthma were diagnosed by routine clinical tests: clinical history, skin tests, total IgE and specific IgE. In addition ECP and EPX were determined in serum. All patients were asymptomatic, stable and without medical treatment. Methacholine challenge test (MCT) was performed in all patients. MCT were positive in 4 patients of group I and 45 patients of group II. ECP levels (ug/l) were: 21 (I), 24 (II) and 7 (III). EPX levels (ug/l) were 35 (I), 45 (II) and 21 (III). Statistical differences (p < 0.01) were observed both in ECP and EPX levels in patients with MCT positive in relation to patients with MCT negative, and in allergic patients (I and II) in comparison with the healthy subjects (III) (p < 0.01). ECP and EPX serum levels are increased in patients with a positive MCT in the winter, out of the pollen season, when patients are asymptomatic, stable and without treatment. This fact suggests that eosinophils play an important role in the pathogenesis of bronchial asthma.     

Early prediction of outcome in score-identified, postcardiac surgical patients at high risk for sepsis, using soluble tumor necrosis factor receptor-p55 concentrations

OBJECTIVE: To investigate the prognostic value of increased serum concentrations of soluble tumor necrosis factor (TNF) receptors in patients at high risk for sepsis. DESIGN: Prospective study. SETTING: Cardiac surgical intensive care unit in a University Hospital. PATIENTS: Those 27 of 870 consecutive postcardiac surgical patients who met a previously validated high-risk criterion for imminent sepsis (Acute Physiology and Chronic Health Evaluation II [APACHE II] score of > or = 24 on the first postoperative day [day 1]). In this population, systemic inflammatory response syndrome was present in 96% of the patients and the in-hospital mortality rate was 30%. In addition, ten postcardiac surgical patients with an uncomplicated course (mortality rate 0%) were studied for comparison. INTERVENTIONS: Blood sampling for measurements of serum concentrations of TNF and soluble TNF receptors 55 kilodalton (TNF receptor-p55) and 75 kilodalton (TNF receptor-p75) on days 1, 2, 3, and 5. MEASUREMENTS AND MAIN RESULTS: Compared with the ten patients with an uncomplicated course (group A), the high-risk patients had significantly higher baseline (day 1) serum concentrations of soluble TNF receptor-p55 (9.2 vs. 4.2 ng/mL) and soluble TNF receptor-p75 (9.2 vs. 5.5 ng/mL). These high-risk patients could be further differentiated into two subgroups: one (B) with a prompt decrease in APACHE II score and a good prognosis (mortality rate 0%) and another (C) with a persisting high risk of sepsis and mortality rate (40%, p < .05). Although baseline APACHE II score was similar in both high-risk subgroups, soluble TNF receptor-p55 concentrations were significantly higher in subgroup C compared with subgroup B already at baseline (10.7 vs. 4.7 ng/mL). The receiver operating characteristic curve for subgroup classification by soluble TNF receptor-p55 was in a discriminating position with an area (0.773 +/- 0.096), confirming soluble TNF receptor-p55 as a predictor of mortality. TNF and soluble TNF receptor-p75 concentrations were less predictive at baseline. CONCLUSIONS: This study suggest that increased soluble TNF receptor-p55 concentrations in the serum of postcardiac surgical patients allow earlier prognostication of subsequent hospital course than APACHE II scores alone. This study further suggests that the combination of physiologic scores and cytokine receptor measurements could improve the predictive power of early postoperative risk stratification.     

Effects of clozapine and haloperidol on baseline levels of vacuous jaw movements in aged rats

BACKGROUND: IgE-mediated hypersensitivity to latex proteins has become a significant clinical problem over the last decade. Nursing and medical staff are at risk because of their occupational exposure to latex. AIMS: To determine the prevalence of type I hypersensitivity to latex allergens in the nursing staff of an Australian hospital. METHODS: A questionnaire which asked about symptoms associated with the use of latex gloves was completed by 140 nurses working in the Alfred Hospital (72 in general medical wards, 68 in intensive care units). Skin prick tests with eluates of five different types of latex glove as well as common aeroallergens (rye pollen and house dust mite) and banana extract were performed. RESULTS: Thirty-one nurses (22%) were skin prick test positive to at least one of the five latex glove eluates. All of these nurses were atopic, having positive skin prick tests to rye pollen or house dust mite. Symptoms of local dryness, itch and erythema associated with glove use were reported by more than half the study group, but not more frequently by those who were skin prick test positive to latex. Urticaria associated with glove use was reported more frequently by those with positive latex skin prick tests (13% vs 4%, p = 0.05). Eighty-seven per cent of the nurses who were latex skin test positive were also positive to banana extract. CONCLUSIONS: IgE-mediated hypersensitivity to latex is common in nurses working in an Australian hospital. Glove associated symptoms were frequently reported, but in most cases the symptoms were more typical of irritant or contact dermatitis rather than type I hypersensitivity reactions. However, the extent of subclinical sensitisation to latex found in this study suggests that symptomatic latex allergy is likely to emerge as an increasing problem for nursing staff in this country.     

Beneficial effects of captopril on prognosis in patients with acute myocardial infarction. Shanghai Secondary Prevention of Acute Myocardial Infarction Study Group

OBJECTIVES: To assess the effects of early and long-term angiotensin-converting enzyme inhibitor treatment with captopril on clinical outcome in patients with acute myocardial infarction (AMI). METHODS: Eight hundred and twenty-two patients with AMI who were hospitalised within 72 hours of symptoms and had no cardiogenic shock were randomly allocated to captopril (n = 478, Group I) and conventional treatment (n = 344, Group II). Cardiac events including congestive heart failure, reinfarction, severe arrhythmias and cardiac death during hospitalization and follow-up period (average 20 months) were determined. RESULTS: The overall mortality rate during hospitalization was lower in group I than in group II (P = 0.0001), this was true for patients with anterior (P = 0.0003), inferior (P = 0.0411) and anterior inferior AMI (P = 0.0232). During follow-up, despite similar occurrence rate of reinfarction and severe arrhythmias in the two groups, the mortality rate (P = 0.0324) and total cardiac event rate (P = 0.055) were lower in group I than in group II. CONCLUSIONS: After AMI, early and long-term treatment with captopril exerts a beneficial effect on the prognosis of patients.     

HLA B27 and respiratory involvement in axial spondylarthropathies. A retrospective study in 107 male patients

OBJECTIVE: To conduct a retrospective study of respiratory involvement in axial spondylarthropathies according to HLA B27 status. METHOD: Sch?ber's index, chest expansion and lung function parameters were measured in 107 male inpatients with spondylarthropathies, including 78 with and 29 without the HLA B27 antigen (groups I and II, respectively). Active or severe spondylarthropathy was defined based on widely used clinical and laboratory test parameters. RESULTS: The two groups were similar regarding age, body mass index, disease duration, proportion of smokers and proportion of patients requiring nonsteroidal antiinflammatory drug therapy. Overall, 30 patients had pure active disease, 11 had pure severe disease, 26 had active severe disease and 40 had nonactive nonsevere disease. Group I patients were significantly more likely to have active severe disease than group II patients, whereas the opposite was true for nonactive nonsevere disease. Mean erythrocyte sedimentation rate was higher in group I (22.6 +/- 21.6) than in group II (13.3 +/- 12.5) (P = 0.039). Group I patients had lower values for chest expansion (5.4 +/- 2.2 cm versus 6.37 +/- 1.9 cm; P = 0.045), vital capacity (91.9% +/- 13.9% versus 99.5% +/- 17.6%; P = 0.021), and total capacity (91.8 +/- 12.3 versus 98.1 +/- 13.9; P = 0.025). A restrictive defect was found in 12 group I patients versus one group II patient (nonsignificant difference). All patients with restrictive defects had active and/or severe disease. Two-way analysis of variance and Fisher's PSLD post-test suggested that lung function was influenced by disease severity but not by disease activity. CONCLUSION: Lung function impairment may be more common and more severe in HLA B27-positive than in HLA B27-negative spondylarthropathy patients. This difference may be entirely ascribable to increased disease severity in HLA B27-positive patients.     

Relaxation of canine pulmonary arteries caused by stimulation of atypical beta-adrenergic receptors

BACKGROUND: Although in some cases delayed hypersensitivity may be observed, beta-lactam antibiotics frequently induce immediate allergic IgE-mediated reactions with the specificity localized in the acyl-side chain structure. Generally, delayed immunologic reactions are related to sensitized T lymphocytes and major histocompatibility complex restricted. OBJECTIVE: To investigate the prevalence of HLA class I and II antigens in patients with delayed hypersensitivity to aminopenicillins in order to evaluate a relationship between major histocompatibility complex immune response genes and aminopenicillins hypersensitivity. METHODS: We assessed 24 patients with history of delayed hypersensitivity to aminopenicillins using (1) skin test with penicilloyl polylysine, minor determinant mixture, benzylpenicillin, amoxicillin, and ampicillin; (2) patch tests with benzylpenicillin, amoxicillin, and ampicillin; (3) RAST for penicilloyls G and V; and (4) oral challenges with amoxicillin, ampicillin, and penicillin V in 18/24 patients. All patients were typed by microlymphotoxicity standard test for HLA class I and II antigens. Statistical analysis by chi2 test 2 x 2 contingency tables, according to Svejgaard, were used for comparison between patients and random Italian population (522 subjects). RESULTS: In the patients group we found higher prevalence of HLA A2 (12/24 = 50%, RR = 6.76 P < .001, EF = 0.425), DRw52 (20/24 = 83.3%, RR = 9.28, P < .001, EF = 0.74), and lower frequency of DR4 (3/24 = 12% ns). CONCLUSIONS: These data suggest that the immune mechanisms involved in adverse reactions to aminopenicillins in vivo are related to genetic markers of immune response and confirms that the presentation of penicillin-hapten determinants to lymphocyte is major histocompatibility complex restricted.     

Intrarenal hemodynamic abnormalities in diabetic nephropathy measured by duplex Doppler sonography

Intrarenal hemodynamics were studied by duplex Doppler sonography in 112 inpatients with type II diabetes mellitus (DM; 65 males, 47 females, 58 +/- 13 years old). The resistive index (RI) and pulsatility index (PI) of the interlobar arteries were calculated. The patients were divided into four groups: group I consisted of patients with urinary albumin excretion (UAE) < 20 micrograms/min (N = 42), group II with 20 < or = UAE < 200 (N = 28), group III with UAE > or = 200 (N = 25), and group IV with serum creatinine > or = 1.5 mg/dl (N = 17). Both RI and PI values in groups II, III, and IV were significantly higher than those in the controls (age- and sex-matched healthy persons, N = 37; P < 0.001), and those in group IV were significantly higher than those in groups I, II, and III (P < 0.0001). Multiple regression analysis revealed that RI values in DM patients were significantly affected by creatinine clearance, age, and duration of diabetes (R2 = 0.554, P < 0.0001). When intima-medial thickness (IMT) of the femoral and carotid arteries were measured by B-mode ultrasonography, RI values were significantly correlated with both the femoral and carotid arterial IMT. These results demonstrate that intrarenal hemodynamic abnormalities are present in type II DM patients with nephropathy, and that intrarenal hemodynamics are affected by decreased glomerular function and also probably by advanced arteriosclerosis.     

Genetic and antigenic analysis of human rotavirus prevalent in Al-Taif, Saudi Arabia

The subgroup, serotype and electropherotype diversity of human rotavirus strains was investigated in Al-Taif, Saudi Arabia. Out of 349 faecal samples collected from diarrhoeic children, 150 (43 percent) tested rotavirus positive by a group-A specific enzyme-linked immunosorbent assay (ELISA). The majority (87 percent) of the infected children were below 2 years of age. Subgrouping and serotyping of rotaviruses with specific monoclonal antibodies showed that of the 150 rotavirus positive specimens, 17 percent belonged to subgroup I, 59 per cent belonged to subgroup II, and 24 percent were neither subgroup I nor subgroup II. The specimens were typed, as serotype 1 (43 percent), serotype 2 (5 percent), serotype 3 (11 percent), serotype 4 (10 percent) or mixed serotypes (3 percent). The remaining 41 (27 percent) specimens were untypeable. None of the serotypes showed association with a particular age group. An electrophoretic analysis of viral RNA revealed 11 distinct patterns (six long and five short). The majority, 78 percent were long patterns and 22 percent were short patterns. Analysis of the specimens for which subgroups, serotypes and electropherotypes were available indicated that a given RNA pattern does not correspond to a particular subgroup or serotype.     

Improvement of the cement mantle of the acetabular component with bone cement spacers. A retrospective analysis of 200 cemented cups

A discontinuous or thin cement mantle of a socket is associated with increased polyethylene wear and cement fractures. In a retrospective radiological analysis we examined the quality of the cement mantle in cups without (group I = 100 Charnley-Mueller cups) and with (group II = 100 Contemporary cups, Howmedica) bone cement spacers. Under-filling (0-2 mm) and over-filling (> 8 mm) of the cement mantle were noted and classified. Statistics show significantly less under-filling of the cement mantle in group II than in group I (P = 0.001), in particular when comparing separate cup regions (thirds: P < 0.001). Furthermore, there is no significant difference in the frequency of overfilling with cement between groups I and II (P = 0.108). To sum up, utilization of an acetabular component with performed bone cement spacers considerably improves the quality of the cement mantle without additional cost.     

Interferon-gamma in the treatment of systemic sclerosis: a randomized controlled multicentre trial

We report the results of a randomized controlled multicentre study on interferon-gamma (IFN-gamma) treatment of systemic sclerosis as determined by skin sclerosis, renal and other organ involvement, global assessment, subjective symptoms and quality of life. Forty-four patients were enrolled into the trial, 27 in the treatment group and 17 in the control group. All patients presented with type I or type II scleroderma. Twenty-nine patients (64%) finished the study. The mean duration of Raynaud's phenomenon and skin sclerosis was 15.3 and 10.8 years, respectively. The skin scores tended to improve in the treatment group (P > 0.05). Mouth aperture increased significantly from 38.5 to 47.7 mm in the treatment group (P < 0.001). Subanalysis of IFN-gamma treated patients with normalized skin sclerosis scores >/=1 showed significant improvement in both skin involvement and subjective symptoms (P < 0.05). Organ involvement improved in eight of 18 treatment patients and in three of 11 control patients. It worsened in three of 18 treatment patients and in four of 11 control patients. One control patient died due to cardiorespiratory failure during the study. No deterioration of renal function occurred during IFN-gamma treatment. There was a significant improvement in quality of life parameters in the control group but not in the treatment group. Plasma levels of neopterin increased significantly during IFN-gamma treatment but not in the control group, whereas N-terminal procollagen III peptide levels did not change in either group. There was a high frequency of mild to moderate influenza-like adverse events during IFN-gamma treatment. Only four of nine drop-out patients, however, experienced symptoms most probably associated with IFN-gamma treatment. We conclude that IFN-gamma therapy has mild beneficial effects on skin sclerosis and disease-associated symptoms in type I and II scleroderma. IFN-gamma treatment was associated with acceptable tolerability and did not induce major renal dysfunction in our patients.     

An atypical presentation for primary sclerosing cholangitis

We describe the clinical course of a group of patients with primary sclerosing cholangitis who at presentation were diagnosed to have autoimmune hepatitis. The history of one such patient is described in detail. We also compare this atypical sclerosing cholangitis (group I) to typical sclerosing cholangitis (group II) and to autoimmune hepatitis with (group III) and without (group IV) cholestasis. At presentation, mean AST in groups I and III was similar and significantly higher than in group II (P < 0.05). Mean ALP was higher in sclerosing cholangitis than in autoimmune hepatitis but not significantly so. Triaditis was present in all patients in groups I, III, and IV. Piecemeal necrosis and multilobular collapse/fibrosis were equally frequent in groups I, III, and IV. Only the response to corticosteroids helped differentiate among groups. Groups III and IV responded by normalizing AST. In group I, AST improved, but never became normal. As ALP became disproportionately abnormal (ALP-predominant pattern), cholangiography was performed, and the diagnosis of primary sclerosing cholangitis was made in all group I patients. We recommend that cholangiography be performed early in patients with suspected autoimmune hepatitis who partially respond to corticosteroids and develop an ALP-predominant pattern.     

Salvage of the diabetic foot with exposed os calcis

Fifty consecutive heel ulcers were managed in three groups by debridement, split-thickness skin graft (STSG), bypass procedures, and orthotics. Group I consisted of 24 ulcers in patients with diabetes (DM) and peripheral vascular disease (PVD), 14 patients in Group II with DM only, and 12 patients with PVD only (Group III). Healing occurred in 56.5%, 64.3%, and 83.3%, respectively. An average of 2.2 procedures were performed per patient. Follow-up periods were for a minimum of two years or until amputation. Time for complete healing and the number of amputations performed were similar in all groups. Of the diabetics (combined from Groups I and II), a subgroup of 27% required partial excision of the os calcis to facilitate closure. After saline dressing changes, STSG was accomplished over thin granulation tissue. Forty percent of this subgroup healed, 30% remained open, and 30% were amputated. Aggressive management, soft-tissue coverage, and orthotic use can lead to a functional weight-bearing extremity.