Improved method for i.r. determination of the degree of N-acetylation of chitosan

Three published i.r. absorption band ratios for determining the % N-acetylation of chitosan have been used to follow the rate of alkaline deacetylation of chitin. Only one, the A1655/A3450 ratio, gives the expected rate of deacetylation curve. Consideration of the various i.r. ratios has led to a new relationship, % N-acetylation = (A1655/A3450) x 115, where the absorbance of the amide I band at approximately 1655 cm-1 is determined using the baseline proposed previously. The values obtained using this proposed relationship agree closely with those obtained from dye adsorption measurements for chitosans having % N-acetylation values in the range 0-55%.

Giant cell carcinoma of the lung exhibiting a large, well-circumscribed photon deficiency in ventilation/perfusion scintigrams

Giant cell carcinoma is a specific clinicopathological entity because of its fulminating clinical behavior and peripheral location in the lung. We present two patients with rapidly fatal giant cell carcinoma; each 99mTcMAA and/or 133Xe ventilation scintigrams showed a large, discrete, photon-deficient area in the lung. This unique scintigraphic finding may result from the peripheral location and rapid grawth of the giant cell tumor. Since giant cell carcinoma is a specific clinicopathological entity and of definite significance in establishing the prognosis of patients with lung cancer, 99mTcMAA and/or 133Xe scintigraphic findings may be useful in revealing such a tumor.

Prevention of ultraviolet-light-induced herpes labialis by sunscreen

Sunlight exposure is reported by some patients to precede onset of recurrent herpes labialis. Ultraviolet (UV) B light is known to be a stimulus for the reactivation of herpes simplex virus (HSV) infections. We assessed the effect of a sunblocking agent on UV-light-induced reactivation of recurrent herpes labialis in a double-blind, placebo-controlled crossover trial. 38 patients were exposed on two separate occasions to four minimum erythema doses of UV light at an area of previous labial herpes recurrence. A solution containing sunscreen was applied to the lips before one exposure and a matched placebo before the other. After placebo and UV exposure, herpes labialis developed in 27 (71%) of the 38 patients, with a mean time to recurrence of 2.9 (SEM 0.2) days. In contrast, when sunscreen was applied before UV exposure, no lesions developed, but 1 of the 35 patients shed virus at the exposure site. We conclude that UV light is a potent stimulus for inducing reactivation of herpes labialis, and that application of sunscreen may be effective in the prevention of sunlight-induced recurrent infection.

Technology assessment in the Framingham Heart Study

To assess the role of observational data bases in technology assessment, we examined 26 articles from the Framingham Heart Study that evaluated a technology, therapy, or predictive instrument. These assessments were grouped into four categories: (a) the study of a technology voluntarily in use by the cohort, (b) the application of an external technology to members of the cohort, (c) the use of the Framingham results to evaluate an unrelated assessment, and (d) the use of the results to validate predictive instruments from other studies. Factors that contribute to the ability of the study to assess voluntary and external technologies include long-term follow-up, a stable cohort, and storage of such nonnumeric data as cardiograms and blood samples. Framingham results have been used to determine outcome measures in later studies. Although the Framingham Study was not designed to assess a technology, we found that large-scale, observational data bases can and do contribute to technology assessment.

A prospective study of the effects of acyclovir treatment on the HSV-2 lymphoproliferative response of persons with frequently recurring HSV-2 genital infections

In a randomized double-blinded fashion, herpes simplex virus type 2 specific lymphocyte proliferation (HSV-2-LP) was studied in patients with frequently recurring genital HSV-2 who were administered daily suppressive oral acyclovir (S-ACV) or placebo and acyclovir for 5 d (PLC/ACV) with recurrences. The pretreatment HSV-2-LP of subjects was low compared with that of controls with infrequently recurring genital HSV-2 (54,000 vs. 110,000 cpm). The HSV-2-LP increased with both S-ACV and PLC/ACV (101,000 and 94,000 cpm, respectively). After treatment was stopped, the HSV-2-LP decreased in both groups (59,000 cpm). Similar data were seen in a subpopulation given a second year of S-ACV. HSV recurrences were reduced in the S-ACV but not in the PLC/ACV group. These data suggest that a low HSV-2-LP in untreated patients is associated with frequent recurrences of genital HSV; a reduction of viral antigens by suppression with ACV or early treatment of HSV recurrences augments the HSV-2-LP response; and the recurrence pattern is not modulated by the HSV-2-LP response.

Atypical mycobacteria causing pulmonary disease: rapid diagnosis using skin test profiles

Purified protein derivatives (PPDs) prepared from M tuberculosis (PPD-S), M kansasii (PPD-Y), M scrofulaceum (PPD-G), M avium (PPD-A), M intracellulare (PPD-B), and M fortuitum (PPD-F) were used simultaneously as skin tests to elicit profiles of reactivity in patients with clinical pulmonary disease roentgenologically suggestive of mycobacteriosis. These profiles were useful in delineating the specific cause of mycobacterial disease weeks before bacteriologic confirmation by culture, and they provided a basis for early treatment. When bacteriologic confirmation was attained, the diagnosis suggested by skin testing was correct. Treatment regimens for non-M tuberculosis (atypical) mycobacterial disease varied: a two- to three-drug regimen in the treatment of M avium or M intracellulare disease was ineffective and inappropriate, whereas a five-drug regimen without surgical excision of residual disease produced good results. Combining surgical resection with the five-drug regimen before and after operation produced the best results, however, with all patients showing apparent cure.

Subrenal capsule assay: feasibility of transporting tissues to a central facility for testing

Hepatic hemangioma patients with Kasabach-Merritt syndrome have reportedly been cured by liver transplantation. However, liver transplantation as a potential cure for a stable patient without Kasabach-Merritt syndrome remains debatable. We report the case of a 27-year-old female patient with a giant hepatic hemangioma. The hemangioma measured 50 × 40 × 25 cm in size and weighed 15 kg, which is the largest and heaviest hemangioma reported in the literature. The patient showed jaundice, ascites, anemia, and appetite loss; but no disseminated intravascular coagulation was observed through laboratory findings. We successfully operated using a right lobe graft without the middle hepatic vein from a 55-year-old donor. At the long-term follow-up, the patient experienced two acute rejections, which were confirmed by biopsy. However, the patient still survives with good graft function after 50 months.

Effect of three single doses of oxmetidine administered intravenously on the volume and acidity of gastric secretion, serum prolactin and gastrin concentration in healthy volunteers

Gastric acid secretion was measured in six healthy volunteers following the intravenous administration (over 30 min.) of oxmetidine 200 mg, 400 mg and 800 mg in a randomized double blind trial for 12 hours. Gastric aspirates were fractionated into hourly aliquots and pH, volume, gastric acidity and gastric acid output were determined. Total gastric acid output over 12 hours was significantly reduced from 24.4 mmol/12 h (median) after placebo to 13.5 mmol/12 h, 11.8 mmol/12 h and 7.7 mmol/12 h after oxmetidine 200 mg, 400 mg and 800 mg respectively. An inhibition of at least 90% was achieved with all doses of oxmetidine and this lasted dose-dependently for 4 to 6 hours. A rise in pH to greater than 5 occurred during the 2nd or 3rd hour after dosing which lasted for 2-5 hours depending on the dose administered. Mean hourly pH was dose-dependently significantly higher for 4-6 hours following oxmetidine treatment than after placebo. A significant reduction in gastric acidity after oxmetidine infusion was also observed while the reduction in volume output calculated for 12 hours was not statistically significant. No significant rises in serum gastrin levels were observed with the oxmetidine doses used. Three out of the six subjects tested showed an increase in serum prolactin levels in response to the highest dose of oxmetidine but this was not statistically significant. The results of the present study have shown that the administration of 400 mg oxmetidine did not cause a longer pH elevation greater than 5 than 200 mg, while with 800 mg side effects were observed in one of the six subjects studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma methotrexate levels in patients with gestational trophoblastic neoplasia treated by two methotrexate regimens

Plasma methotrexate levels were measured in six patients with nonmetastatic and three patients with "low-risk" metastatic gestational trophoblastic neoplasia who were treated by two different methotrexate regimens. Five patients were treated with 16 cycles consisting of methotrexate, 1 mg/kg (days 1, 3, 5, and 7) followed in 24 hours by citrovorum factor, 0.1 mg/kg (days 2, 4, 6, and 8). Cycles alternated between intravenous and intramuscular administration. Statistical differences in plasma levels were found at 1 and 48 hours between the two routes of administration but probably were not of clinical importance. The plasma levels at the time of citrovorum factor administration were below that necessitating citrovorum factor rescue. Four patients were treated with alternating cycles of intravenous or intramuscular methotrexate, 0.5 mg/kg for 5 consecutive days without citrovorum factor. A total of 15 cycles demonstrated no difference in plasma levels at 1, 12, and 24 hours between intravenous and intramuscular administration. Statistical differences in plasma methotrexate levels were noted between the two methotrexate regimens only with intramuscular administration but were not of clinical importance. The reduced toxicity of the methotrexate-citrovorum factor may be due to the scheduling of the methotrexate and not to the citrovorum factor.

Radionuclide diagnosis of diaphragmatic rupture with hepatic herniation

Seven surgically proven cases of a traumatic rupture of the right hemidiaphragm with a hepatic herniation were preoperatively diagnosed by radionuclide liver-spleen imagings, and they were retrospectively analyzed. All injuries resulted from blunt traumatic injury including automobile accidents, and there were associated pelvic and rib fractures in five cases. All patients developed some degree of dyspnea in the relatively immediate phase. All chest radiographs showed an apparent elevation of right hemidiaphragm. Radionuclide liver-spleen imaging with 99mTc sulfur colloid characteristically demonstrated a distortion of liver configuration with superior and posterior displacement of the right lobe. Four patients had a large tear in the central tendon of the right hemidiaphragm, and none had a tear in the anterior part or in left lobe of the liver. The differential diagnosis of elevated right hemidiaphragm is briefly discussed. It is concluded that the correct preoperative diagnosis of the diaphragmatic rupture with liver hernia could be made with an awareness of this condition following trauma and radionuclide liver-spleen imaging.

Treatment of first episodes of genital herpes simplex virus infection with oral acyclovir. A randomized double-blind controlled trial in normal subjects

We performed a double-blind placebo-controlled trial of oral acyclovir in the treatment of first episodes of genital herpes simplex virus infections in 48 young adults (31 women and 17 men). Subjects were randomized to receive either placebo or acyclovir (200 mg per dose) five times daily for 10 days; they were examined on at least eight visits until healed and at monthly visits thereafter. Acyclovir treatment, as compared with placebo, significantly reduced virus shedding, new lesion formation after 48 hours, and the duration of genital lesions in both men and women. The total duration and severity of clinical symptoms (such as pain, adenopathy, dysuria, and malaise) were significantly reduced by acyclovir in both men and women by the third and fourth day, respectively (P less than or equal to 0.025), as compared with placebo. No toxicity was observed. Recurrence rates have so far been similar in placebo and acyclovir recipients. Oral acyclovir treatment of first-episode genital herpes simplex virus infections is clinically effective, but it does not seem to prevent virus latency or associated recurrent disease.

Carcinoma arising in the neovagina: case report and review of the literature

Carcinoma arising in the neovagina is unusual. A case of squamous cell cancer arising in a neovagina constructed by split-thickness dermal graft is reported. This is the fifth reported case of primary cancer of the neovagina; 2 adenocarcinomas and 2 squamous cell carcinomas were reported previously. Primary carcinoma of the neovagina is a distinct clinical entity because of the younger age of occurrence and the histopathologic type.

The role of bougienage in the management of achalasia--the need for reappraisal

Passive dilatation, advocated in the past by a number of gastroenterologists as the initial therapy for achalasia, has fallen into disrepute in the last 15 years. Our recent experience with five achalasia patients, four of whom were judged too fragile for esophageal myotomy or forcible dilatation, indicates the need for reappraisal of bougienage therapy.

Mixed Mullerian tumors of the uterus: clinical and pathologic correlations

The 10-year experience at The Johns Hopkins Hospital with 61 cases of mixed Mullerian tumors were reviewed. The patients had a mean age of 63.7 years and the similar constitutional factors of diabetes mellitus, hypertension and nulliparity of endometrial adenocarcinoma. Only one patient had estrogen exposure. Eighteen percent had had prior exposure to pelvic radiation. The life table survival of the 61 patients was 41.1% at 5 years. The 2-year life table survival was 76% for disease confined to the uterus and 16.5% for extrauterine disease. There was no difference in survival between homologous and heterologous tumors. The surgical staging and the autopsies reviewed documented widely disseminated disease even when the tumor appeared to be confined to the uterus. It thus appears essential in order to improve survival these patients require aggressive staging and consideration of systemic adjuvant chemotherapy.

Peritoneal venous shunting for ascites: a 15-year perspective

Intractable ascites is an incapacitating condition for the patient and a difficult management problem for the physician. Three different shunts have been evaluated in 26 patients over a 15-year period and, on the basis of this experience, recommendations are made to avoid some of the technical problems with peritoneal venous shunts. Nine patients had a Hyde shunt, 12 had a LeVeen shunt, and five patients had a Denver shunt. Operation was performed only after failure of medical management during a 2-24-week period of hospitalization. Four patients had malignant ascites, two nephrogenic ascites, and the remaining 24 patients had ascites secondary to alcoholic liver disease. The type of shunt used did not appear to be critical, as the results were similar in the three groups. The morbidity rate of 57% (operative deaths and need for revision) and the fact that only 27% were alive after one year emphasize that improvements are desirable. Methods to avoid technical problems influencing malfunction of the device are stressed.

Infarction of the optic nerve head in children with accelerated hypertension

Four cases of anterior ischaemic optic neuropathy occurred in children with accelerated hypertension. The cause may have been a sudden relative fall in arterial pressure which reduced the perfusion of the optic disc, whose circulation was compromised by long-standing hypertensive vascular disease.

Spectrum of 2,8-dihydroxyadenine urolithiasis in complete APRT deficiency

APRT deficiency may be totally benign or life threatening. The importance of early recognition/diagnosis is thus stressed. Urolithiasis (2,8-DHA stones: the precipitating factor in all cases) is treatable. With early recognition and treatment allopurinol without alkali and a diet low in purine homozygotes have remained clinically and biochemically normal to date. 'Uric acid' stones in children must always be suspect and subjected to sophisticated analysis. Diagnosis from red cell APRT activity may also have its pitfalls.

The role of thymectomy in red cell aplasia

Red cell aplasia is an unusual cause of anemia. Fifty percent of all patients with red cell aplasia will have a thymoma. Twenty-five to 30% of those who undergo thymectomy will be cured. Data are presented that suggest that any patient with red cell aplasia should have thymectomy through a median sternotomy. One of 3 such patients who underwent the operation has had complete remission for two years.

Mustard operation for transposition of the great arteries in a 3-day-old infant, complicated by acute renal failure

A successful operative treatment of a three day old girl with transposition of the great arteries is described. Post-operative course was complicated by furosemide resistant anuria which was treated by peritoneal dialysis. At the age of eight months, she is a pink, active baby, developing normally. This case report demonstrates the importance of aggressive treatment of severe congenital heart lesions in the first few days of life. The importance of post-operative care is emphasized.

Multicomponent gas chromatographic analysis of urinary steroids excreted by an infant with a defect in aldosterone biosynthesis

The urinary steroids excreted by an infant with a salt-wasting syndrome due to a suspected defect in the 18-oxidation of corticosterone have been analysed by gas chromatography-mass spectrometry. The excretion of tetrahydroaldosterone was low (3.5 mug/24 h) whilst the excretion of 3alpha,11beta,21-trihydroxy-5alpha-pregnan-20-one (allo-tetrahydrocorticosterone) and other corticosterone metabolites was high (total about 2 mg/24 h). The excretion of cortisol metabolites was apparently normal for age (total about 2 mg/24 h) but 3alpha,11beta,17alpha,21-tetrahydroxy-5alpha-pregnan-20-one (allo-tetrahydrocortisol) rather than tetrahydrocortisone, was the major component of the group. The excretion of an 18-hydroxycorticosterone metabolite 3alpha,18,21-trihydroxy-5beta-pregnane-11,20-dione (18-hydroxytetrahydroCompound A) was higher than normal for infants of this age (between 50 and 200 mug/24 h), suggesting that the defect was in 18-hydroxysteroid dehydrogenase rather than 1,-hydroxylase. In addition, 18-hydroxytetrahydrocorticosterone, another metabolite of 18-hydroxycorticosterone was tentatively identified and it was found that the rate of excretion of this compound was of similar magnitude to 18-hydroxytetrahydroCompound A. The salt balance of the infant has been sucessfully controlled by salt administration (77 mEq./24 h) and treatment with Fludrocortisone (0.5 mg/day).