Phaeochromocytoma with myocarditis managed with alpha-methyl-p-tyrosine

A case of bilateral phaeochromocytoma with catecholamine-induced myocarditis is described. The two operations needed allowed comparison of the use of alpha-methyl-p-tyrosine alone and in conjunction with adrenergic blocks in the management of the patient. The combination of both drugs was particularly successful in the relief of symptoms and reduction of catecholamine metabolism as monitored by 4-hydroxy-3-methoxymandelic acid (HMMA) excretion. As myocarditis is a potentially fatal complication, further investigation of the combined use of alpha-methyl-p-tyrosine and adrenergic blocking drugs is suggested in the pre-operative management of patients with phaeochromocytoma.     

Factors related with compliance with tuberculosis chemoprophylaxis

OBJECTIVES: To determine therapeutic tolerance and compliance level with antituberculous chemoprophylaxis. PATIENTS AND METHODS: 587 patients were proposed for antituberculous chemoprophylaxis with isoniazid from January 1995 to June 1996 in Murcia (Spain). RESULTS: 3.6% of the patients gave up treatment because of hepatic intolerance and 73% completed the prophylaxis. Non-compliance related factors were: social risk factors (odds ratio [OR] = 9.31), previous history of allergies (OR = 2.87), previous personal history of tuberculosis-related events (OR = 0.49) and interaction between sex and age. CONCLUSIONS: Support and intervention measures directed to risk groups of a social origin deem to be needed. Control measures and information provided to middle-aged males, with particular emphasis to the first weeks of prophylaxis, should also be implemented.     

Communication with parents of children with cancer

The authors summarize the results of recent work evidencing the existence of latent merozoites during the course of the erythrocytic cycle of the rodent Plasmodia. These merozoites, unlike the majority of merozoites released at schizogony, do not penetrate immediately into the erythrocytes and remain latent for a variable length of time. The merozoites of each of the species or subspecies show marked peculiarities which are responsible for the characteristics of their cycle. The presence of latent merozoites free in the blood, the asynchronous development, and the resistance to chloroquine, are three closely related factors. Knowing that the merozoite is so far drug resistant, and that latent merozoites can maintain the infection for any length of time, it appears important to take into account these purely biological data, when studying the drug resistance of the human falciparum malaria.     

Surgical outcome in patients with epilepsy with occult vascular malformations treated with lesionectomy

PURPOSE: This retrospective study reports the long-term surgical outcome of patients with medically refractory epilepsy and vascular malformations who were treated with lesionectomy. A detailed analysis of surgical failures had been performed in an attempt to define predictors of surgical success and failure. METHODS: Fifteen patients with medically intractable epilepsy and angiographically occult vascular malformations (AOVMs) were treated surgically with lesionectomy at Duke University Medical Center. Lesionectomy consisted of removal of the AOVM and surrounding hemosiderin-stained brain only, without the use of electrocorticography (ECoG) to guide resection. RESULTS: Eleven (73%) patients are seizure free after lesionectomy. Three showed no significant improvement, and one patient died, presumably after a seizure. Age of onset, duration of seizures, age at resection, and gender did not affect outcome. All patients with neocortical AOVMs in whom EEG findings correlated with the site of the lesion were seizure free after lesional resection. Treatment failures were associated with the presence of multiple intracranial lesions, poorly localized or diffuse EEG findings, discordant positron emission tomography (PET) imaging, or with a lesion in close proximity to the limbic system. CONCLUSIONS: Lesionectomy, with removal of surrounding hemosiderin-stained brain, can be considered the procedure of choice in carefully selected patients with epilepsy with occult vascular malformations.     

Patients with malignant meningitis presenting with neuropsychiatric manifestations

BACKGROUND: Malignant meningitis is often thought of as a late event in the course of cancer. At one time, it was thought to be rare, but it has been recognized more frequently in recent times. Clinical suspicion of malignant meningitis is prompted by neurologic symptoms and signs in patients at risk for this oncologic complication. Neuropsychiatric symptoms previously were not considered as presenting symptoms of malignant meningitis. METHODS: Three patients with cancer with no neurologic symptoms were examined for malignant meningitis based on neuropsychiatric symptoms. Cerebrospinal fluid was examined for malignant cells to confirm the diagnosis of malignant meningitis. RESULTS: The clinical presentation of malignant meningitis for three patients was neuropsychiatric. None of the patients had delirium during their initial presentation. CONCLUSIONS: It is important that clinicians recognize that psychiatric symptoms without neurologic findings may indicate malignant meningitis and that malignant meningitis needs to be included in the differential diagnosis of neuropsychiatric disorders in patients with cancer.     

Patient satisfaction with time spent with their physician

AIMS: The aim of the study was to compare the effects of meloxicam and piroxicam on the gastroduodenal mucosa in healthy adults. METHODS: Forty-four healthy volunteers were given a 28 day course of either meloxicam 15 mg, piroxicam 20 mg or placebo. Damage to the oesophageal, gastric and duodenal mucosa was assessed, mucosal blood flow (MBF) measured at endoscopy and biopsies taken for prostaglandin content and microscopic assessment of damage before NSAID administration and during days 1, 7 and 28 of continued intake. RESULTS: Maximal macroscopic gastric mucosal damage (median grade+IQR) occurred within 24 h of piroxicam administration, the damage score increasing from 0 to 2.5 (0-3) (P=0.02) at day 1 before falling to 2.0 (0-2) at day 7 and 0 (0-1) at day 28 with resolution of damage observed in six out of the seven subjects who sustained acute injury. No significant macroscopic gastric damage occurred in either of the two other groups although some minor damage was observed in seven subjects taking placebo and five taking meloxicam. There was a trend towards piroxicam causing more acute gastric damage than meloxicam (P=0.06). Baseline antral, body and duodenal MBF were similar in all three groups. No significant changes occurred in any of the groups on any of the visits. There were also no changes in gastric mucosal prostaglandin content in any group. CONCLUSIONS: These observations suggest that meloxicam causes little acute damage to the upper gastrointestinal tract and piroxicam causes some acute gastric injury but such damage resolves in most subjects by 28 days.     

以质量求生存以特色求发展--关于新建本科院校发展问题的思考

近几年来，新建本科院校从数量和规模上得到了较大发展。本文从新建本科院校的办学定位、人才培养质量、办学特色等方面进行了一些有益的探讨，提出了可以借鉴的方法和思路。     

Women's satisfaction with medical abortion with RU486

The combination of RU486 (mifepristone) and prostaglandin analogues has been used for medical abortion in several European centres. We surveyed 41 Australian women who successfully used this method of abortion in a World Health Organization-sponsored trial. Overall, the women were satisfied with the method and found the associated pain level acceptable.     

Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with Herbert screws

We retrospectively reviewed the results for thirty-four patients in whom a non-union of the scaphoid had been treated with bone-grafting and internal fixation with use of one of two types of screws as well as the temporary placement of Kirschner wires parallel to the screw to prevent rotation. The patients were divided into two groups: Group 1 contained sixteen patients who had been managed with a Herbert screw from 1986 through 1989 and Group 2, eighteen patients who had been managed with a 3.5-millimeter cannulated AO/ASIF screw from 1990 through 1992. There were no clinical or radiographic differences between the two groups. The time to union, confirmed with tomography, was 7.6 +/- 3.6 months for Group 1 and 3.6 +/- 1.2 months for Group 2. This difference was significant (p < 0.01). Both screws significantly improved the alignment of the scaphoid and decreased carpal collapse (p < 0.05). Regardless of the type of screw used, the time to union was significantly shorter when the screw had been placed in the central one-third of the scaphoid (p < 0.05). Seventeen of the eighteen cannulated screws had been placed centrally, compared with seven of the sixteen Herbert screws (p < 0.01).     

Blast-furnace operation with pulverized-coal injection and with chunk anthracite

In order to replace expensive coke, various fuels are added to the blast sent to the blast furnace: pulverized coal, natural gas, coke-oven gas, fuel oil, etc. A less common alternative is to introduce chunk anthracite through the charge hole. The use of chunk anthracite may considerably reduce the coke consumption and the production costs of the hot metal in circumstances where pulverized-coal injection is not employed and its introduction would require the use of high-quality iron ore and coke and also special preparations of the furnace and the associated systems. Chunk anthracite proves especially effective where there are constraints on the furnace productivity on account of production problems, the furnace is switched to slower operation, and plant economics must be improved.     

Subcutaneous infusion anesthesia with prilocaine diluted with Ringer's lactate

BACKGROUND: Dermatologic surgery is usually possible under local anesthesia, even when large amounts of highly diluted anesthetic solutions are required (tumescent anesthesia). Although special pumps now render such large injections effortless, it is usually still necessary to hold and guide the injection cannula. We have overcome this handicap by injecting anesthetic solutions slowly with an infusomat, which allows slow painless automatic infusion into the subcutaneous layer. METHOD: The speed of infusion varied between 40 ml and 1500 ml per hour depending on location, size of the operation, and needle size. Volumes usually ranged from 1 ml to 500 ml but rose as high as 1000 ml if necessary. We found it easier to inject larger amounts than with the conventional method. We used 21-gauge to 30-gauge needles with a length of 1 to 10 cm. The anesthetic solution was prilocaine (Xylonest), and the dilution liquid was original Ringer's solution in 500 ml bottles with no additives. The concentration of the solution varied between 0.4% and 0.1%. After setting up the system, the physician even can leave the room. Especially for children and very anxious patients, this feature is calming. MATERIAL: We used this type of subcutaneous infusion anesthesia (SIA) in our department to treat 502 patients ranging in age from 3 to 92 years (mean age: 51 years). We performed all kinds of tumor operations (n = 213), dermabrasions (n = 5), scar revisions (n = 21), stripping of the long and short saphenous veins (n = 82), sentinel node dissection (n = 27), complete lymph node dissection of the axilla (n = 12) and groin (n = 17), and 125 other operations as well. RESULTS: There were no severe complications. Postoperative recovery was fast. 110 (91%) of 121 patients who had previously experienced other forms of anesthesia for the same kind of operation preferred SIA. CONCLUSIONS: SIA Ringer's solution diluted prilocaine is an economical, safe and comfortable technique for nearly all skin operations, even for children and very sensitive patients.     

Communicating with metaphor: a dance with many veils

Health practitioners face many challenges when caring for and communicating with dying persons. As truth-tellers, we search for ways to communicate with honesty, sensitivity, and compassion. Creative use of language is one aspect of caring. Metaphorical communication can be a healing modality, one consistent with communication as an art. This article suggests that metaphor is a powerful and sensitive form of language that offers a range of characteristics particularly suitable for the art and the challenge of communicating with dying people. Metaphor, as figurative language, provides a permissible way of saying one thing and meaning another. It allows us to share a truth without the glare of reality. This author contends that metaphor is mysterious, creative, invitational, safe, open to interpretation, respectful and playful. The creative and judicious use of metaphor provides health care practitioners with many veils--veils that shield the dying from the glare of their prognosis, veils particularly valuable and suited in communicating with our palliative patient population.     

Long-term treatment with lansoprazole for patients with Zollinger-Ellison syndrome

BACKGROUND: Normalization of gastric secretion and cure of associated upper gastrointestinal lesions by resection of gastrinoma is possible in approximately 20% of patients with Zollinger-Ellison syndrome, leaving approximately 80% dependent on medical treatment with proton pump inhibitors for acid suppression. METHODS: Lansoprazole was given for 3-48 months (median 28 months) to 26 Zollinger-Ellison syndrome patients with peptic ulcer manifestations in all and oesophagitis in 13. Starting with 60 mg/day. the dose was individualized to lower basal acid output to less than 5 mmol/h for those with intact stomachs and less than 1 mmol/h in those who had prior gastrectomy or with oesophagitis. The patients were studied every 3 months for 1 year and then every 6 months with gastric analysis (basal and maximal acid and pepsin output) and endoscopy with biopsy for enterochromaffin-like (ECL) cells. RESULTS: Lansoprazole inhibited basal acid output by 95%, pepsin output by 65% and remained effective at the initial mean (66 +/- 4.3 mg/day) or smaller doses (56 +/- 12 mg/day) at 48 months. Mucosal lesions healed and symptoms (ulcer-type pain, diarrhoea, heartburn, weight loss) resolved rapidly, usually within a few weeks. Serum gastrin and ECL cell populations, which were elevated before treatment, remained statistically unchanged but one of the three multiple endocrine neoplasia I (MEN-I) patients developed a small carcinoid. Of the three patients with metastatic gastrinoma at diagnosis one has died and one has progressed, while the third has had stable liver metastases for 26 years. Ulcer-type relapses occurred in three of the five post-gastrectomy patients, one with fatal jejunal ulcer perforation despite adequate acid suppression. No biochemical or clinical adverse events due to lansoprazole were encountered. CONCLUSION: Lansoprazole effectively inhibits acid and pepsin secretion in Zollinger-Ellison syndrome patients without any demonstrated side-effects. Despite strict acid control, post-gastrectomy Zollinger-Ellison syndrome patients were more liable to ulcer relapse, while oesophagitis was not a marker for therapeutic difficulty.