Ambulatory blood pressure and Holter monitoring of emergency physicians before, during, and after a night shift

BACKGROUND: Patients with a mutation in the LDL receptor gene (familial hypercholesterolemia, or FH) are characterized by substantial elevations in plasma LDL cholesterol and are at higher risk of developing coronary artery disease (CAD). Correlates of abdominal obesity may also contribute to the risk of ischemic cardiac events. Whether the hyperinsulinemic-insulin-resistant state of abdominal obesity affects coronary atherosclerosis among FH patients has not been determined. METHODS AND RESULTS: The relation of abdominal adiposity and hyperinsulinemia to angiographically assessed CAD was evaluated in a sample of 120 French Canadian men aged <60 years who were heterozygotes for FH and in a group of 280 men without FH. In the present study, the risk of CAD associated with abdominal obesity, as estimated by the waist circumference, was largely dependent on the concomitant variation in plasma lipoprotein and insulin concentrations. In contrast, the association between fasting insulin and CAD was independent of variations in waist girth, triglyceride, HDL, and apolipoprotein B concentrations (odds ratio, 1.86; P=.0005). However, the most substantial increase in the risk of CAD was observed among abdominally obese (waist circumference >95 cm) and hyperinsulinemic FH patients (odds ratio, 12.9; P=.0009). This increase in risk remained significant even after adjustment for LDL cholesterol or apolipoprotein B concentrations. CONCLUSIONS: Results of the present study provide support for the notion that the hyperinsulinemic-insulin-resistant state of abdominal obesity is a powerful predictor of CAD in men, even in a group of patients with raised LDL cholesterol concentrations due to FH.     

Ambulatory patient-activated arrhythmia monitoring: comparison of a new wrist-applied monitor with a conventional precordial device

Sensitivity of forced expiratory flow between 25% and 75% of the vital capacity (FEF25-75) in detecting airway obstruction was investigated in 14 children with mild-moderate asthma, allergic to house dust mites, while at high altitude (1756 m). Forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1), FEF25-75, and peak expiratory flow (PEF) were measured every 2 weeks for 12 weeks (total, 84 measurements). The presence or absence of wheezing at the chest auscultation was ascertained before each test. During the study period, a significant improvement of both mean (SD) FEF25-75 [61 (12)% vs. 68 (11)% of the predicted value, p = 0.005] and PEF [95 (16)% vs. 103 (13)%, p = 0.002] was observed. FEV1 changed only marginally [82 (7)% vs. 86 (6)%, p = 0.05]. Wheezing was present on 12/84 occasions. Wheezing was associated with abnormal FEF25-75 values on most occasions but not with abnormal FEV1 or PEF. FEF25-75 was decreased on 51% of days in which wheezing was absent. FEV1 and PEF were, respectively, normal in 69% (p < 0.0001) and 92% (p < 0.0001) of measurements in which FEF25-75 was abnormal. These results suggest that FEF25-75 may be considered a good indicator of airflow obstruction and a sensitive marker of respiratory improvement in asthmatic children during reduced antigen exposure.     

Resetting of tremor by mechanical perturbations: a comparison of essential tremor and parkinsonian tremor

With the use of a computer-controlled torque motor, experiments were carried out on 11 patients with essential tremor and 13 with parkinsonian tremor to determine the effect of mechanical displacements at the wrist joint on the established pattern of tremor. Analysis of the timing of tremor bursts in electromyographic recordings before and following the stimuli revealed that the phase of essential tremor could be readily reset by external perturbations. In the majority of the parkinsonian patients the same type of stimuli had very little effect on the pattern of tremor. Differences between predicted and actual times of occurrence of tremor bursts following the stimuli were used to calculate a normalized resetting index, with 0 representing no resetting and 1, complete resetting. For the patients with essential tremor the mean resetting index was 0.64 +/- 0.14 (SD); for the parkinsonian patients the generation of essential tremor. Reflex mechanisms are less important in parkinsonian tremor, which is more likely dependent on oscillations originating in the central nervous system.     

"Anatomical M-mode": a new echocardiographic technique potentially useful in the quantitative study of the left ventricle

According to the data collected at the Rome-based National Reference Centre for Enterobacteria, 266,547 Salmonella strains isolated from human sources (226,513) and from non human sources (40,034) were characterised in Italy during the period 1973-1995. The serotype of all isolates, and the antibiotype and phage type of selected isolates were determined. Human-source isolations grew from 4372 in 1973 to 12,310 in 1995: non-human source isolations, from 339 in 1973 to 3459 in 1995. Salm. Typhimurium ranked first in the list of the most common serotypes isolated from both sources in the period 1973-1988 except in the years 1975 and 1976 when it was overtaken by Salm. Wien. Since 1983 Salm. Enteritidis has been among the top ten isolates from animals, and ranked first in the list of isolates from humans in 1988 and from non human sources in 1991. During the last years the number of multidrug-resistant strains, mostly belonging to phage types 104 and 193 of Salm. Typhimurium has been rising. Salmonella strains have also been isolated from numerous extraintestinal infections, almost exclusively caused by Salm. Enteritidis and Typhimurium.     

Emergent textural contours: a new technique for visual monitoring in nystagmus, oculomotor dysfunction, and accommodative disorders

Emergent textural contours, the perceptual effect seen during continuous rotation of symmetrical arrays of uniform pattern elements, provide a unique source of visual feedback for eye movements and resolutional states and have potential for use as a new clinical tool. The phenomenon is produced by a combination of factors including the effects of visual persistence and differential resolution. A total of 28 subjects including 17 normals, 4 nystagmus, 4 oculomotor dysfunction, and 3 accommodative facility cases were shown an emergent textural contour with an instrument (the Goldrich Contour Rotator) for its display. Subjects were enabled to monitor their own eye movements and accommodative training. Nystagmus subjects were provided with a continuous source of visual input reflecting their ocular oscillations and a determination of the null point of nystagmus was made with the instrument.     

Starplasty: a new technique of pediatric tracheotomy

OBJECTIVE: To report a new technique of pediatric tracheotomy that reduces the problems of pneumothorax and recannulation after accidental decannulation in a recently performed tracheotomy. DESIGN: Retrospective chart review for 1990-1997. PATIENTS: Sixty-eight children aged between 2 days and 14 years. METHOD: The starplasty procedure is based on the geometry of a 3-dimensional Z-plasty. The technique of the procedure is described and illustrated in detail. RESULTS: There were 27 short-term complications, including 4 accidental decannulations. There were no instances of pneumothorax or tracheotomy-related deaths. There were 25 long-term minor complications. There were no instances of tracheotomy-related death, suprastomal collapse, or tracheal stenosis. Thirty-eight children remain tracheotomy tube dependent, 17 underwent decannulation, 7 died of primary disease, and 6 were lost to follow-up. All 17 children who underwent decannulation have a persistent tracheocutaneous fistula. CONCLUSIONS: I conclude that starplasty reduces the incidence of major complications and death. Its only drawback seems to be persistent tracheocutaneous fistula.     

Mental visualization before and after problem presentation: a comparison

Three experiments were carried out to study the effects on problem solving of visualization when subjects (secondary-school students and undergraduates) were instructed to generate mental images before the problem was presented and when they received such a hint after being given the problem. In each experiment an arithmetic, a geometric, and a practical problem were presented in three different conditions, a control condition, an "imagery-before" condition, and an "imagery-after" condition. Analysis showed that, in general, the "imagery-after" task helps subjects to overcome the misleading or fixating tendencies which interfere with problem solution; in contrast, the "imagery-before" task may enhance such tendencies.     

Lumbar epidural perineural injection: a new technique

Molecular variants of individual components of the renin-angiotensin system (RAS) are reported to constitute the inherited predisposition to some cardiovascular diseases in man, e.g. essential hypertension or myocardial infarction. The frequency of these variants depends highly on the race and population. Therefore, we examined the M235T molecular variant of the angiotensinogen gene and the I/D polymorphism of the ACE gene in Slovak healthy population, in patients with diagnosed essential hypertension and in patients who had undergone myocardial infarction. DNA from 241 subjects was tested for the presence of M235T and I/D molecular variants. The frequency of both these polymorphisms in the Slovak population is similar to other Caucasian populations. In the group of hypertensive patients, the frequency of the M235T molecular variant was increased compared to controls, predominantly in males (0.45 vs. 0.28), while in the I/D polymorphism the incidence of the D allele was the same for both controls and hypertensives (0.49 vs. 0.50). A significant increase in the D allele frequency compared to the controls occurred in the group of infarcted patients (0.63). The increased frequency of the M235T allele in hypertensive patients compared to the healthy population confirms that the M235T variants associated with increased blood pressure in the Slovak population. In the Slovak population, I/D polymorphism of the ACE gene is associated with myocardial infarction rather than with hypertension.     

Duplex ultrasonography: a noninvasive technique in monitoring of Le Veen shunt

Monitoring of peritoneovenous Le Veen shunt by duplex ultrasonography was first performed in 1993 in 10 patients. The duplex signal was picked up selectively in the venous tube and the peak velocity was measured at forced inspiration. Thirty-two examinations were performed. Of these, 13 had follow-up examinations by other modalities (radionuclide imaging, shuntography, or surgical exploration), all of which confirmed the findings of duplex ultrasonography. Shuntography was avoided in all instances with a patent shunt. Duplex ultrasonography allows noninvasive assessment of Le Veen shunt patency and appears reliable for determining the need for invasive diagnostic modalities or surgical shunt correction.     

The effect of head-to-trunk position on the direction of arm movements before, during, and after space flight

This contribution deals with the examination of the consequences of different head-to-trunk positions on arm movements under normal gravity and during prolonged space flight. One of the objectives of this study was to investigate the influence of weightlessness on the condition of the spatial analysis system. Aimed arm movements in the horizontal plane (pointings towards two visual targets) were recorded, first with eyes open, head straight (learning part), then with eyes closed, head straight and during yaw or roll position of the head (performance part). Measurements related to these different head-to-trunk-positions were taken in one short-term and nine long-term cosmonauts preflight, inflight, and postflight. Terrestrial control experiments were carried out with an extended experimental design in 14 healthy volunteers. The analysis of these experiments revealed that, with eyes closed and the head in yaw position, cosmonauts before flight and control subjects exhibit significant slants of the movement plane of the arm. Contrary to terrestrial measurements, in space experiments roll tilt of the head to the right is correlated with considerable counterclockwise slant of the movement plane. This slant of the movement plane of the arm was interpreted as tilt of the internal representation of the horizontal coordinate. The effect is larger with greater distortion induced by the changed head position and with larger muscular involvement to keep this position. This effect is also increased by the reduction of information (for example, in microgravity). The amount and the direction of the horizontal offset of the arm movements are shown to be dependent on the head-to-trunk position, too. Additionally, we have found changes in the amplitude and in the duration of the arm movement, in the vertical offset, and in the curvature of the movement paths, depending on the experimental conditions.     

Ambulatory treatment of hemorrhoidal pathology with elastic bands according to a modified Barron technique

The authors report their experience in the treatment of hemorrhoids by rubber band ligation according to Barron's modified technique which foresees that the ligation is performed thanks to the suction of the hemorrhoidal node through the shaft of the band applicator connected with an aspirator. Eighty-four patients underwent consecutively this treatment over a 18-month period; all were performed with a minimum follow-up of 6 months. Forty male patients (mean age 46.6 years) showed symptoms lasting since 9 years. Forty-four female patients (mean age 42.6 years) showed such pathology since 8.9 years. 70.2% of the patients were classified as III stage of disease, 19% II stage and 10.7% I stage. Thirty-four patients had anal pain, 49 bleeding, 5 anemia, 21 thrombosis of the hemorrhoidal plexus, 54 prolapse of the ano-rectal mucosa. These symptoms and signs were present in most of the patients contemporaneously. Three patients had previously received rubber band ligations, 4 hemorrhoidectomy, 1 sclerotherapy and 1 rubber band ligation and sclerotherapy. In the whole we performed 285 sessions and 304 rubber band ligations. Each treatment consisted of 3.4 sessions and 3.6 rubber band ligations. Recovery was achieved with only one session in 9 patients; 66.7% of them showed 1st degree disease. Multiple sessions were necessary in patients with advanced disease degree; 100% at stage II and 94.9% at stage III. Sixty-five patients did not refer immediate and long-term significant complications. The remaining patients complained during the first hours about heavy feeling and/or tenesmus and two, 2 weeks after the end of treatment, showed bleeding episodes, which cleared up spontaneously. In 5 cases it was necessary, during follow-up, to carry out a completion rubber band ligation and in 3 we performed trimming surgery at the out-patients' department by resection of the exceeding skin and anal mucosa. The technique enables to achieve results just as valid as those of traditional methods in the treatment of hemorrhoidal pathology with the advantage that it can be performed in an out-patient's department, it does not need local anesthesia, it enables the patient to immediately return to his normal working activity and, restricted to the observation period (6- and 12-month follow-up) it allows a satisfactory control of the disease.     

Laparoscopic cholangiography: a new technique for difficult cannulation

PURPOSE: To test the hypothesis that rejection could affect the contractility and contractile reserve of left ventricle after heart transplantation. METHODS: Echocardiographic parameters and noninvasive blood pressure end-systolic pressure (ESP), heart rate (HR), end diastolic (EDV) and end-systolic (ESV) volumes, ejection fraction (EF), end-systolic stress (ESS) and the end-systolic relation (ESS/ESV) were recorded in 68 studies in 11 patients, seven days-12 months after heart transplantation. Accordingly with the endomyocardial biopsies results were divided into two groups: group A-with no rejection (53 studies), and group B-with rejection (15 studies). RESULTS: The nitroprusside infusion changed significantly and in the same way, all the parameters except the ESS/ESV ratio (A = 5.5 +/- 1.7 x B = 4.8 +/- 1.5 g/cm2/mL, p = NS); there was a decrease in ESP (A = 107 +/- 15 and B = 109 +/- 12 mmHg, p = NS), EDV (A = 68 +/- 19 and B = 81 +/- 12 mL, p = NS), ESV (A = 12 +/- 5 and B = 18 +/- 12 mL, p = NS) and ESS (A = 59 +/- 13 and B = 82 +/- 20g/cm2, p = NS); there was an increase in HR (A = 94 +/- 9 and B = 93 +/- 16bpm, p = NS) and EF (A = 83 +/- 5 and B = 79 +/- 8%, p = NS). In the dobutamine study it was observed differences for both groups, except for ESP (A = 156 +/- 26 and B = 149 +/- 26mmHg, p = NS). The increase in HR, EF and ESS/ESV ratio was greater in group A (HR-A = 117 +/- 19 and B = 102 +/- 25bpm, p < 0.05; EF-A = 91 +/- 4 and B = 78 +/- 11%, p < 0.05; ESS/ESV-A = 13.1 +/- 6 and B = 6.1 +/- 3.1 g/cm2/mL, p < 0.05). For group A it was smaller the EDV (57 +/- 18 x 94 +/- 35 mL, p < 0.05), ESV (5 +/- 3 x 24 +/- 20 mL, p < 0.05) and ESS (57 +/- 21 x 102 +/- 40 g/cm2, p < 0.05). CONCLUSION: Rejection may not induce changes in resting left ventricular contractility, however, the contractile reserve is depressed during an episode of moderate to severe rejection.     

Essential tremor: a review of pathogenic mechanisms

INTRODUCTION: Essential tremor (ET) is the commonest involuntary movement observed and is seen when a given posture is maintained. Although it does not affect life expectancy, it may cause considerable functional disability and serious psychological effects in the affected person. DEVELOPMENT: ET is a heterogeneous clinical condition. Its physiopathology is still not known, is very complex and involves many mechanisms, both structural and biochemical, although as yet there is no theory to include them all. In view of what is known at present, it may be accepted that there is a central oscillator at olive-cerebellar-thalamic-cortical-spinal level, which is the primary generator of ET, modulated by a peripheral component. The tremor results from interaction between increased central excitability and peripheral regulation, which in turn reinforces the central overactivity. It may also be that the monoaminergic system (catecholaminergic and serotoninergic), adrenoreceptors (especially the B2 muscular adreno-receptors) and the bodily structure itself, amongst other factors, may influence the pathogenic mechanism of ET. It is likely that there is a multifactorial genetic disorder which predetermines this physiopathogenic process, although this has not yet been determined. CONCLUSIONS: In this paper we review the various hypotheses and existing knowledge related to the aetiopathogenesis of TE.     

Chairside-fabricated indirect resin restorations: a new articulated technique

A case report of a chairside-fabricated indirect resin composite restoration is used to introduce a modification to a newly released one-appointment resin inlay-onlay technique. Fast-setting poly(vinyl siloxane) die material accommodates an articulated working cast within 10 minutes. The technique allows the economical construction of large, occlusal, load-bearing, extracoronal resin composite restorations. The guarded prognosis associated with extensive posterior resin composite restorations is acknowledged; nevertheless this technique remains a realistic option for those financially compromised patients who request tooth-colored restorations.     

External cantilever sling in septorhinoplasty: a new technique

Development of mucoperichondrial and mucoperiosteal flaps bilaterally, total removal of the deviated septum, straightening it outside, followed by replacement as a free graft constitute an option in treatment of the severely deviated nose. Positioning and stabilization of the septum in this technique may prove insufficient in the majority of septorhinoplasty patients in whom both nasal bones are also immobilized. Positioning and stabilization can be achieved adequately by the use of the presented technique that involves passing a 3-0 nylon suture to suspend the cartilage replant to a plastic splint applied to the dorsum of the nose, one-third of which is taped over the realigned nasal bones. In the past 5 years, 45 patients have undergone septorhinoplasty using this technique. The minimum follow-up period was 6 months. No patient developed any major complications. Secondary correction was necessary to improve the aesthetic result in only one patient. The results in patients who underwent this surgical procedure suggest that the presented technique provides excellent results in severely deviated noses associated with major deviations of the septum but must be limited only to those whose deformity is so severe that other techniques will be insufficient to obtain the desired result.     

EEG-blocking before and during voluntary movements: differences between the eyes-closed and the eyes-open condition

Movement-related EEG periods of 1 s duration were analyzed by fast Fourier transformation in the Bereitschaftspotential (BP) paradigm in 21 healthy, right-handed normals. Spectra of the rest period and the BP period before the onset of the voluntary movement, and of the rest period and the movement period, were compared in order to describe blocking effects before and during movement execution (fast fist closure of the right hand). When comparing the rest period and the movement period with the eyes closed as well as with the eyes open, blocking was pronounced in both conditions within the total frequency range of the alpha-band, especially at positions contralateral to the movement over the motor cortex (C3') and the parietal cortex (P3) as well as at the parietal midline electrode (Pz). Moreover, when comparing the spectra of the rest and the BP periods in the eyes-closed condition, significant differences were again seen, with lower values during the BP period at C3' and P3. We were, however, able to observe over the parietal cortex an increase of alpha power in the 10 Hz range during the BP period with the eyes opened and fixated. This increase during the BP period in the eyes-open condition was not found when the eyes were closed. This paradoxical phenomenon of an increase of power with the eyes opened instead of blocking during the BP period, as observed in the eyes closed, may be due to an additional activation effect on the already activated (blocked) EEG in the eyes-open condition during fixation.