Splenic hypofunction in cirrhosis is not associated with increased risk for infections

Femoral artery pseudoaneurysm is a major problem in patients undergoing cardiac catheterization. This study describes our experience with 5 French (5 F) and 7 French (7 F) introduction sheaths and 7 investigators at our institution regarding the incidence of pseudoaneurysms. During 54 months (1/1990-6/1994) 8715 consecutive patients after diagnostic cardiac catheterization were first clinically checked for pseudoaneurysm and in case of suspicion a duplex sonography was performed. In 86 (1%) patients, 44 (52%) women and 42 (48%) men, mean age 63 +/- 9.7 years we observed this complication by duplex ultrasound. 54 (62%) patients had arterial hypertension, 18 (20%) diabetes and only 3 (3.6%) had peripheral arteriosclerosis. An antithrombotic medication was used in 60% (52 patients). As compared to a control group of 450 consecutive patients a pseudoaneurysm was significantly more likely to occur in patients with a history of hypertension (63% vs 25%, p < 0.0001). Women are also at higher risk representing 51% of all pseudoaneurysms as compared to 29% in the control group (p < 0.0001). Using 7-F catheters more pseudoaneurysms occurred (82/7183; 1%) than using 5 F (4/1532; 0.2%) introduction sheaths (p = 0.0005). There were also significantly more pseudoaneurysms caused by investigator 1 (21/787; 2.7%) as compared to the other investigators (65/7829; 0.8%), (p = 0.0002). Investigator 1 had a more distal puncture technique than the others. Pseudoaneurysms complicating cardiac catheterization occur 5-times more frequent using 7 F (1%) as compared to 5 F catheters (0.2%). Moreover distal puncture site is associated with a higher frequency of pseudoaneurysms.     

Alkalinization of lidocaine does not hasten the onset of axillary brachial plexus block

We assessed the onset of sensory and motor blockade as well as the distribution of sensory blockade after axillary brachial plexus block with 1.5% lidocaine hydrochloride 1:200,000 epinephrine with and without sodium bicarbonate in 38 patients. The onset of analgesia and anesthesia was recorded over the distributions of the median, ulnar, radial, and medial cutaneous nerves of the forearm, medial cutaneous and lateral cutaneous nerves of the arm, and musculocutaneous nerve. The onset of motor blockade of elbow and wrist movements was also recorded. Data were analyzed by using survival techniques and compared by using log rank tests. Only the onset of analgesia in the medial cutaneous nerves of the arm and forearm, and the onset of anesthesia in the medial cutaneous nerve of the arm were significantly faster (P < 0.05) with alkalinization of lidocaine. Our study showed that alkalinization of lidocaine does not significantly hasten block onset in most terminal nerve distributions. IMPLICATIONS: We examined whether alkalinizing a local anesthetic would quicken the onset of a regional upper limb nerve blockade. We found that alkalinization of lidocaine did not offer a significant clinical advantage in axillary brachial plexus blockade.     

Initial high anti-emetic efficacy of granisetron with dexamethasone is not maintained over repeated cycles

We have reported previously that the anti-emetic efficacy of single agent 5HT3 antagonists is not maintained when analysed with the measurement of cumulative probabilities. Presently, the most effective anti-emetic regimen is a combination of a 5HT3 antagonist plus dexamethasone. We, therefore, assessed the sustainment of efficacy of such a combination in 125 patients, scheduled to receive cisplatin > or = 70 mg m(-2) either alone or in combination with other cytotoxic drugs. Anti-emetic therapy was initiated with 10 mg of dexamethasone and 3 mg of granisetron intravenously, before cisplatin. On days 1-6, patients received 8 mg of dexamethasone and 1 mg of granisetron twice daily by oral administration. Protection was assessed during all cycles and calculated based on cumulative probability analyses using the method of Kaplan-Meier and a model for transitional probabilities. Irrespective of the type of analysis used, the anti-emetic efficacy of granisetron/dexamethasone decreased over cycles. The initial complete acute emesis protection rate of 66% decreased to 30% according to the method of Kaplan-Meier and to 39% using the model for transitional probabilities. For delayed emesis, the initial complete protection rate of 52% decreased to 21% (Kaplan-Meier) and to 43% (transitional probabilities). In addition, we observed that protection failure in the delayed emesis period adversely influenced the acute emesis protection in the next cycle. We conclude that the anti-emetic efficacy of a 5HT3 antagonist plus dexamethasone is not maintained over multiple cycles of highly emetogenic chemotherapy, and that the acute emesis protection is adversely influenced by protection failure in the delayed emesis phase.     

Addition of fentanyl to 1.5% lidocaine does not increase the success of axillary plexus block

The stroke volume of the left ventricle (SV) was calculated from noninvasive recordings of the arterial pressure using a finger photoplethysmograph and compared to the values obtained by pulsed Doppler echocardiography (PDE). A group of 19 healthy men and 12 women [mean ages: 20.8 (SD 1.6) and 22.2 (SD 1.6) years respectively] were studied at rest in the supine position. The ratio of the area below the ejection phase of the arterial pressure wave (A(s)) to SV, as obtained by PDE, yielded a "calibration factor" dimensionally equal to the hydraulic impedance of the system (Zao = A(s).SV-1). The Zao amounted on average to 0.062 (SD 0.018) mmHg.s.cm-3 for the men and to 0.104 (SD 0.024) mmHg.s.cm-3 for the women. The Zao was also estimated from the equation: Zao = a.(d + b.HR + c.PP + e.MAP)-1, where HR was the heart rate, PP the pulse pressure, MAP the mean arterial pressure and the coefficients of the equation were obtained by an iterating statistical package. The value of Zao thus obtained allowed the calculation of SV from measurements derived from the photoplethysmograph only. The mean percentage error between the SV thus obtained and those experimentally determined by PDE amounted to 14.8 and 15.6 for the men and the women, respectively. The error of the estimate was reduced to 12.3 and to 11.1, respectively, if the factor Zao, experimentally obtained from a given heart beat, was subsequently applied to other beats to obtain SV from the A(s) measurement in the same subject.     

The practical use of axillary brachial plexus block for hand surgery

A retrospective study of 178 patients undergoing axillary brachial plexus block (ABPB) for hand surgery used information gathered by a computer-aided anaesthetic record keeping system. The practical use of local techniques to augment the block meant that only two of the 178 patients required a general anaesthetic, giving a success rate of 98.8%. There were no significant complications.     

Arm adduction does not increase block extension in anesthesia of the brachial plexus by the axillary approach

INTRODUCTION: Arm abduction of 90 degrees during injection of local anesthetic followed by adduction of the arm has been recommended traditionally to favor proximal distribution of local anesthetic and extension of the blockade in the brachial plexus by the axillary route. A recent study demonstrated that there are no clinical or radiological differences between axillary blockades performed with abduction or adduction. OBJECTIVE: To compare the extension of sensory blockade in axillary anesthesia performed with adduction or abduction. MATERIAL AND METHODS: Forty patients were randomly distributed in two groups, 20 in the adduction group and 20 in the abduction group. The axillary catheter was inserted 3 cm in the proximal direction and a mixture of 40 ml of 1.5% mepivacaine without adrenaline and 4 ml of 8.4% bicarbonate soda was injected into each patient. RESULTS: No statistically significant differences in extension of sensory blockade, including circumflex, musculocutaneous and radial nerve blockade, were observed. CONCLUSIONS: Axillary rotation of the arm is not a determining factor in sensory blockade in brachial plexus anesthesia by the axillary route.     

Chronic relapsing brachial plexus neuropathy with persistent conduction block

Idiopathic brachial plexus neuropathy (BPN) is an immune-mediated disorder characterized by an acute onset of painful weakness in one or both upper extremities. The course is usually monophasic with gradual improvement over months; however, occasionally BPN can recur. Electrophysiologic studies suggest the pathogenesis is primarily axonal in the majority of cases. We describe an unusual case of BPN in which the patient had a chronic and relapsing course of painless weakness associated with conduction blocks and other electrophysiologic features of demyelination across the brachial plexus. The patient improved following treatment with intravenous immunoglobulin. The neuropathy falls within the spectrum of chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy.     

An unusual toxic reaction to axillary block by mepivacaine with adrenaline

An increase in blood pressure, accompanied by atrial fibrillation, agitation, incomprehensible shouts and loss of consciousness, was observed in an elderly, ASA classification group II, cardiovascularly medicated male, 12 min after performance of axillary block with mepivacaine 850 mg containing adrenaline 0.225 mg, for correction of Dupuytren's contracture. After intravenous administration of labetalol, metoprolol and midazolam the patient's condition improved, and 15 min later he woke up. The block was successful and surgery was conducted as scheduled despite persisting atrial fibrillation. Postoperatively, the patient refused DC cardioversion and was treated medically. Both the temporal relationship of events and the response to treatment suggest that a rapid systemic absorption of mepivacaine with adrenaline and/or interaction of these drugs with the patient's cardiovascular medications were responsible for the perioperative complications.     

Cell-cycle progression is not essential for c-Myc to block differentiation

The c-myc proto-oncogene has been shown to cause blockages to differentiation in many cell lineages. Although the mechanism by which c-Myc affects this process remains unknown, it is considered that it might result indirectly as an outcome of the continued cell-cycle progression invoked by c-Myc in cells which must growth arrest in order to differentiate. However, as there is little evidence to support this hypothesis, it is equally possible that a differentiation blockage occurs through a mechanism independent of c-Myc's involvement in cell-cycle progression. To explore this possibility we utilised a differentiation-defective variant of the U937 cell line, which still responds to the differentiation inducer by undergoing rapid growth arrest. Analysis of this line during growth arrest revealed that, although the expression of the Myc target gene, ornithine decarboxylase (ODC) was down-regulated, the cells differed from those of the parental line in that they continued to express high levels of c-Myc protein, but did not maintain high levels of expression of the Myc antagonists, mad1 and mxi1. Moreover, antisense down-regulation of the c-Myc protein levels in these growth-arrested cells revealed that this continued c-Myc expression was essential for their differentiation blockage. These data therefore indicate that c-Myc can block differentiation by a mechanism dissociated from its ability to direct cell-cycle progression or the expression of ODC.     

Horseshoe kidney is associated with an increased relative risk of primary renal carcinoid tumor

PURPOSE: Carcinoid tumor is a rare neoplasm of the kidney with an unknown histogenesis. Of only 31 cases previously reported in the literature 4 arose within horseshoe kidneys. We report a case of primary carcinoid tumor arising within a horseshoe kidney and discuss the unique insight it provided into the pathogenesis of this tumor. MATERIALS AND METHODS: We reviewed in detail all 31 reported cases of renal carcinoid tumor and, using reported incidence rates of horseshoe kidney, we calculated the relative risk of renal carcinoid tumor arising within a horseshoe kidney. Immunohistochemical staining for neuroendocrine related markers was performed on tissue sections from the present carcinoid tumor, the adjacent kidney and 5 control samples of normal renal parenchyma. RESULTS: Of the reported tumors 15.6% occurred in horseshoe kidneys, yielding a calculated relative risk of 62. The present tumor was multifocal, arising from the wall of a cystic lesion and possibly representing a dilated calix within the isthmus. Intestinal epithelium lining the cyst cavity exhibited multifocal neuroendocrine cell hyperplasia with an immunohistochemical profile identical to that of the carcinoid tumor cells. CONCLUSIONS: The relative risk of renal carcinoid tumor developing in a horseshoe kidney is markedly greater than that for Wilms tumor or transitional cell carcinoma. The clinical course of renal carcinoid tumor arising within a horseshoe kidney appears to be more benign than that of the nonhorseshoe variant. Our observations support the hypothesis that renal carcinoid tumors may arise from neuroendocrine cells within foci of metaplastic or teratomatous epithelium within the kidney.     

Anatomic basis of continuous axillary block of the brachial plexus with thoracic reservoir

Although continuous axillary block is effective for periods of up to four to six weeks, pain clinic patients with severe chronic pain in the upper extremities, mainly resulting from neuropathic disease, can require continuous drug delivery by catheter-reservoir for up to three months or longer. We studied possible locations for implanting reservoirs or catheters from the perivascular axillary space in fresh cadavers, checking for possible vascular or nerve damage after applying the usual technique for reservoir implantation. The ideal location for the reservoir is the subcutaneous tissue of the homolateral infraclavicular space of the anterior side of the thorax. The customary procedures for inserting the catheter along the subcutaneous route that extends from the perivascular axillary space to the reservoir carry no risk of damaging vascular or nerve structures.     

Mold allergy is a risk factor for persistent cold-like symptoms in children

In winter, children with mold allergy may develop persistent cold-like symptoms (PCLS) that often defy conventional therapy. To investigate the cause of PCLS, we enrolled 44 children (25 with PCLS and 19 controls) in a 2-year study to compare their clinical symptoms and the mold count in their homes. Children with PCLS had a higher percent of eosinophils in nasal smears as compared with those without PCLS (32% vs 26%). On a scale of 0 to 3, the PCLS group had higher symptom scores (P < 0.001 for all symptoms): bloodshot eyes (2.92 vs 0.79), mouth breathing (2.04 vs 0.68), rhinorrhea (2.48 vs 0.89), nasal voice (2.68 vs 1.00), postnasal drip (2.64 vs 0.47), and headache (2.72 vs 0.53) than the non-PCLS group. The clinical scores also correlated significantly with the mold count in the home (the r value ranged from 0.6716 to 0.7450). We conclude that management of children with PCLS should include decreasing humidity and enforcing environmental control to eradicate mold from inside the homes.     

The small heat shock protein HSP27 is not an independent prognostic marker in axillary lymph node-negative breast cancer patients

Heat shock protein 27 (hsp27) belongs to the family of heat shock proteins and is thought to be involved in thermotolerance, cell proliferation, drug resistance, and chaperone processes. The aim of this study was to investigate whether hsp27 levels are correlated with clinical outcome in axillary lymph node-negative breast cancer patients. We describe a Western blot study measuring hsp27 levels in 425 patients and an immunohistochemistry (IHC) study analyzing 788 patients. Results obtained by both methods were concordant. Univariate survival analysis was performed considering hsp27 either as an optimally dichotomized variable or as a continuous variable. Additional data include age at biopsy, tumor size, estrogen receptor (ER) and progesterone receptor status, tumor ploidy and percentage of cells in S phase, and adjuvant therapy. hsp27 levels correlated positively with ER status (P = 0.0001 in Western blot and IHC study), progesterone receptor status (P = 0.0001 in Western blot and IHC study), and aneuploidy (Western blot study, P = 0.0012; IHC study, P = 0.0004) but not with tumor size (Western blot study, P = 0.69; IHC, P = 0.53) or S phase (Western blot study, P = 0.19; IHC study, P = 0.38). Overall, there was no relationship between hsp27 expression and disease-free survival (Western blot study, P = 0.70/0.54; IHC, P = 0.47/0.30) or overall survival (Western blot study, P = 0.16/0.15; IHC, P = 0.46/0.78). Exploratory subset analyses defined by ER status and use of adjuvant treatment indicated that in ER+/untreated patients, high hsp27 levels correlated modestly with shorter disease-free survival (Western blot, P = 0.04/0.04; IHC, P = 0.11/0. 03). hsp27 is not a useful prognostic marker for the clinic in axillary lymph node-negative patients. However, the finding of modest prognostic value of hsp27 in the subgroup of ER+/untreated patients raises new questions about the biological function of hsp27 in breast cancer.     

Abnormal sensory nerve conduction in multifocal demyelinating neuropathy with persistent conduction block

Two patients exhibited chronic, slightly asymmetric weakness and wasting with fasciculations of the upper limb and hand muscles. Motor nerve conduction studies showed features of multifocal conduction block in nerve segments other than those usually involved in entrapment syndromes. The F wave was markedly delayed in the median and ulnar nerves. Transcranial cortical and cervical root magnetic stimulation showed bilaterally delayed thenar responses with normal central conduction time. Needle electromyography demonstrated a chronic denervation pattern with large polyphasic motor units in several muscles of the upper limbs. Sensory symptoms were mild and limited to paresthesias in the fingertips. Sensory nerve conduction velocity and sensory nerve action potential amplitudes were normal in elbow-to-wrist and wrist-to-finger segments of the median and ulnar nerves, but there was a delayed cortical response and unrecognizable Erb's point and cervical responses in the somatosensory evoked potentials to median nerve electrical stimulation. Electrophysiologic examination was normal in most nerves of the lower limbs. These two patients, meeting clinical and electrophysiologic criteria of multifocal neuropathy with conduction block, demonstrate that sensory fibers may also be involved in this syndrome.     

The heterozygous 20210 G/A prothrombin genotype is associated with early venous thrombosis in inherited thrombophilias and is not increased in frequency in artery disease

A genetic variation in the 3'-untranslated region of the prothrombin mRNA (20210 G/A) has recently been reported to be associated with elevated plasma prothrombin levels and with an increased incidence of venous thrombosis. We determined the frequency of this mutation, the detection of which was improved by allele-specific amplification of exon 14 and by denaturing gradients (denaturing gradient gel electrophoresis), in cohorts of patients affected by venous thrombosis (n = 132) or by coronary or cerebrovascular diseases (n = 195) and in normal subjects from various populations. An overlapping frequency of the heterozygous genotype (4%) was found in normal subjects from Italy and Cyprus, and no carrier was detected in 40 subjects of Indian or Somali origin. The 20210 GA heterozygous genotype was not increased in frequency in patients with arterial disease. In contrast, the GA genotype was associated (P = .007) with venous thrombosis both in simple heterozygotes (16%) with a family history of thrombosis as well as in double heterozygotes (14%) for other known thrombophilic defects. A synergic interaction between the prothrombin 20210 GA genotype and the factor V Leiden mutation, both potentially affecting the prothrombinase complex, was suggested by the early onset of thrombosis (median age 22 years) in doubly heterozygous patients. The association of the 20210 A allele with higher prothrombin levels was confirmed in the Italian population. However, the prothrombin assay does not allow an efficient preselection of patients for the DNA analysis.     

Lithium carbonate therapy is not a risk factor for osteoporosis

Lithium carbonate is a widely used drug for affective disorders. It may effect calcium metabolism and alter parathyroid physiology by causing hypersecretion of parathyroid hormone. Patients treated with this medication might therefore be predisposed to osteoporosis. The purpose of this study was to evaluate the effect of either short- or long-term lithium carbonate therapy on parameters of bone metabolism. Parathyroid function and indices of bone metabolism were assessed in 23 patients treated for affective disorders. 10 patients were treated for 0.4-1.0 year (Group 1), and 13 patients were treated for more than 3 years (Group 2). In all subjects, bone mineral density measurements in the hip and lumbar spine regions were performed using dual energy X-ray absorptiometry. Serum thyroid hormone, PTH, LH, testosterone and urine OH-proline, free cortisol, calcium and phosphate excretion were measured. The two groups were well matched for sex, weight, calcium intake, lithium levels and smoking habits, although Group 2 was slightly older. No differences between the two groups were noted in either bone mineral density or other parameters that were assessed. Urinary OH-proline was elevated similarly in both groups. Our results did not detect any effect on bone density after short- or long-term lithium carbonate therapy, although the data does suggest an increase in bone turnover associated with this treatment. Thus, short- or long-term treatment with lithium is not associated with increased risk for osteoporosis.     

Memory T cell tolerance to superantigens is not due to increased susceptibility to apoptosis

Opioid peptides were analysed in tissue extracts of various brain structures and the pituitary gland from rats sacrificed by microwave irradiation, and compared with peptide levels in tissue extracts from decapitated rats. Dynorphin A, dynorphin B and Leu-enkephalinArg6, derived from prodynorphin, and Met-enkephalinArg6Phe7 from proenkephalin, were measured. Basal immunoreactive levels of dynorphin A and B were consistently higher in extracts from microwave-irradiated rats, whereas in these extracts immunoreactive levels of Leu-enkephalinArg6, an endogenous metabolite of dynorphin peptides, were either lower than, the same as or higher than in decapitated rats. Immunoreactive levels of Met-enkephalinArg6Phe7 were higher in microwave-irradiated rats. Effects of morphine treatment on prodynorphin peptide levels were evaluated and compared with previous findings in decapitated rats. Dynorphin immunoreactive levels were higher in the nucleus accumbens and striatum of morphine-tolerant rats than in corresponding areas in saline-treated rats. These results indicate tissue-specific metabolism of prodynorphin peptides and show that metabolism of opioid peptides occurs during the dissection procedure after decapitation of the rat even though precautions are taken to minimize degradation.