[An asymptomatic aneurysm of the popliteal artery treated with endoprosthesis]

Stent-graft is considered as a possible alternative to traditional surgery in the correction of popliteal aneurysms but only a few cases have been reported and these are difficult to compare. This new case highlights the feasibility and problems of an endovascular approach. The size of the stent was determined on the basis of preliminary arterial scanning and a measurement guide wire. Strong recommendations to the patient to avoid posture-related kinking of the artery and/or the stent (during occupation-related or other activities) could prevent delayed thrombosis of the stent. The lifetime of the stent can be prolonged by a simple radiosurgical clearance procedure.

[Shoulder fusion for sequelae secondary to brachial plexus palsy]

PURPOSE OF THE STUDY

We examined clinical and radiological outcome in fifteen patients who underwent shoulder fusion after brachial plexus palsy.

MATERIAL AND METHODS

This retrospective analysis included 15 patients who underwent shoulder fusion between 1981 and 1997 for the treatment of sequelae secondary to brachial plexus palsy. There were 13 men and two women, mean age 24.6 years (range 18-33 years). The right shoulder was fused in nine cases and the dominant shoulder in ten. There was one obstetric paralysis and one paralysis secondary to a cervical neurinoma. Eleven patients were motorcycle accident victims and two were automobile accident victims. The patients were installed in the lateral supine position with 30 degrees antepulsion and 60 degrees abduction, measured from the axillary axis of the scapula, and internal rotation. All patients had internal fixation by plate through a posterior approach. The same observer examined all the patients at last follow-up. Clinical and radiological findings were recorded and the position of the arthodesis was analyzed.

RESULTS

There was one case of delaved fusion and one case of late humeral fracture. The arthrodesis position was abduction 52 degrees, internal rotation 20 degrees, flexion 20 degrees (means). Hand-mouth and hand-pocket movements were possible for all patients. Seven had no pain. Active motion was: 48 degrees abduction, 46 degrees antepulsion, 40 degrees internal rotation, 4.6 degrees external rotation, 23 degrees retropulsion. For 13 patients, mean lifting force was 5.2 kg.

Peripheral endothelial dysfunction in normal pressure glaucoma

PURPOSE

To assess vascular endothelial function in patients with normal pressure glaucoma using forearm blood flow responses to intra-arterial infusions of endothelial-dependent and -independent vasoactive agents.

METHODS

Eight patients with newly diagnosed and untreated normal pressure glaucoma and eight healthy age- and sex-matched control volunteers underwent measurement of forearm blood flow using venous occlusion plethysmography. Blood flow was assessed in response to incremental doses of sodium nitroprusside (an endothelial-independent vasodilator), acetylcholine (an endothelial-dependent vasodilator) and the vasoconstrictor N(G)-monomethyl-L-arginine (an inhibitor of nitric oxide synthase).

RESULTS

Sodium nitroprusside caused a dose-related increase in forearm blood flow in patients and controls. Glaucoma patients appeared to have an increased vasodilatory response, but this was not significant (P = 0.23). Acetylcholine also induced vasodilatation in both groups, but the response was significantly reduced in the glaucoma group (P = 0.04). N(G)-monomethyl-L-arginine induced a similar degree of vasoconstriction in both groups (P = 0.76).

CONCLUSIONS

This study has shown an impairment of peripheral endothelium-mediated vasodilatation in normal pressure glaucoma. These findings would support the concept of a generalized vascular endothelial dysfunction in patients with this condition.

Reduction mammaplasty: a safe and effective outpatient procedure

Traditionally, reduction mammaplasty has been performed on an inpatient basis with a one to two day hospitalization. Many procedures once commonly performed on an inpatient basis have been shown to be safe and effective when performed in an outpatient setting. The purpose of this study was to determine if reduction mammaplasty could be performed safely on an outpatient basis and to compare findings between inpatient and outpatient groups. An outcome based retrospective review of patients who had bilateral reduction mammaplasty from 1989 to 1993 was performed at two centers. Minimum follow-up was nine months. Of 331 patients, 161 were outpatients and 170 were inpatients. Seventy-six percent of the surgeries were performed in the hospital and 24 percent at a free-standing surgical facility. There were no statistical differences between the two groups when comparing age, marital status, preoperative health status, operative technique, and resection weight. Evaluation of patient body weights, use of antibiotics, and complications did reveal statistical differences between the two groups. The inpatients were heavier, more likely to experience a complication, and less likely to receive antibiotics. There was, however, no difference between the two groups for incidence of rehospitalization, return to the emergency department, or reoperation.A patient satisfaction survey was conducted with both outpatient and inpatient groups reporting high satisfaction with their results. Over 95 percent of patients in both groups felt the experience was a positive one. The survey indicated high patient acceptance of breast reduction on an outpatient basis for the outpatient population. The data confirms that reduction mammaplasty is a safe and effective procedure when performed on an outpatient basis. The cost savings associated with outpatient surgery is significant and an important consideration in this era of health care reform.

A kinetic mechanism for nicotinic acetylcholine receptors based on multiple allosteric transitions

Nicotinic acetylcholine receptors are transmembrane oligomeric proteins that mediate interconversions between open and closed channel states under the control of neurotransmitters. Fast in vitro chemical kinetics and in vivo electrophysiological recordings are consistent with the following multi-step scheme. Upon binding of agonists, receptor molecules in the closed but activatable resting state (the Basal state, B) undergo rapid transitions to states of higher affinities with either open channels (the Active state, A) or closed channels (the initial Inactivatable and fully Desensitized states, I and D). In order to represent the functional properties of such receptors, we have developed a kinetic model that links conformational interconversion rates to agonist binding and extends the general principles of the Monod-Wyman-Changeux model of allosteric transitions. The crucial assumption is that the linkage is controlled by the position of the interconversion transition states on a hypothetical linear reaction coordinate. Application of the model to the peripheral nicotine acetylcholine receptor (nAChR) accounts for the main properties of ligand-gating, including single-channel events, and several new relationships are predicted. Kinetic simulations reveal errors inherent in using the dose-response analysis, but justify its application under defined conditions. The model predicts that (in order to overcome the intrinsic stability of the B state and to produce the appropriate cooperativity) channel activation is driven by an A state with a Kd in the 50 nM range, hence some 140-fold stronger than the apparent affinity of the open state deduced previously. According to the model, recovery from the desensitized states may occur via rapid transit through the A state with minimal channel opening, thus without necessarily undergoing a distinct recovery pathway, as assumed in the standard 'cycle' model. Transitions to the desensitized states by low concentration 'pre-pulses' are predicted to occur without significant channel opening, but equilibrium values of IC50 can be obtained only with long pre-pulse times. Predictions are also made concerning allosteric effectors and their possible role in coincidence detection. In terms of future developments, the analysis presented here provides a physical basis for constructing more biologically realistic models of synaptic modulation that may be applied to artificial neural networks.

Public understanding of medical screening

AIM

To estimate the extent of public understanding of mass screening for disease and of the benefits and limitations of screening.

METHODS

Telephone interviews were conducted with a national sample of 835 Australians.

RESULTS

Of total respondents, 68% claimed to have heard of screening tests, but only 21% correctly understood that screening tests are for asymptomatic people. This understanding was related to education. The most frequently named tests were mammography (51%) and Pap tests (33%), and for all age groups these were mentioned by more women than men. Around 27% of respondents thought that the Pap test would detect 95% or more of case, 45% thought the test would detect 90% or more, while 60% of respondents thought the test would detect 80% or more of cases. Around 29% of respondents thought that mammography would detect 95% or more of cases, 49% thought the test would detect 90% or more, while 65% of respondents thought the test would detect 80% or more of cases. Of all respondents, 33% favoured compensation when cases were "missed" by screening provided people were warned beforehand, 58% were not in favour, and 9% were unsure.

CONCLUSIONS

There are misconceptions among the public concerning the purpose of screening and the accuracy of screening tests. However, most people accept that some cases of disease will be missed by screening and that if people are adequately informed beforehand compensation should not automatically follow for those whose disease is missed.

Synthesis and structure-activity relationships of stilbene retinoid analogs substituted with heteroaromatic carboxylic acids

Retinoids elicit biological responses by activating a series of nuclear receptors. Six retinoid receptors belonging to two families are currently known: retinoic acid receptors (RAR alpha,beta,and gamma) and retinoid X receptors (RXR alpha,beta,and gamma). Stilbene retinoid analogs of retinoic acid (RA), such as (E)-4-[2-(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthalenyl)prope n-1- yl]benzoic acid (TTNPB, 1) and (E)-4-[2-(5,6,7,8-tetrahydro-3,5,5,8,8-pentamethyl-2-naphthalenyl)pro pen-1- yl]benzoic acid (3-methyl-TTNPB, 2), display differential RAR and RXR activities, depending on the substituent at C3 of the naphthalene ring. We report here structural modifications of the benzoate moiety of 2 that result in analogs with greater RXR selectivity as well as those with pan-agonist (activate both RAR and RXR receptors) activities, analyze the structural features that impart receptor selectivity, and describe a stereoselective method for the synthesis of these analogs. The biological activities associated with the RAR and RXR receptors were examined by testing representative examples with different receptor activation profiles for their ability to induce tissue transglutaminase (Tgase) activity in a human promyelocytic leukemia cell line (HL-60 cdm-1) and to inhibit tumor-promoter-induced ornithine decarboxylase (ODC) activity in hairless mouse skin. These results suggest that RAR agonists and RXR agonists may have different therapeutic applications. Finally, we show that RXR agonists are significantly reduced in teratogenic potency relative to RAR agonists and may therefore have significant advantages in clinical practice.

Single dose and multidose analgesic study of ibuprofen and meclofenamate sodium after third molar surgery

The purpose of this study was to compare the analgesic efficacy and safety of meclofenamate sodium with ibuprofen after dental impaction surgery. This study was double-blind and used a unique methodology. Patients (N = 254) were first randomized into the single dose phase of the study that included placebo, meclofenamate 50 mg, meclofenamate 100 mg, ibuprofen 200 mg, and ibuprofen 400 mg, followed by a 7-day multidose phase in which patients in the placebo group were rerandomized into one of the active treatment cells. In the single dose phase, all active treatments were significantly more efficacious than placebo for every summary analgesic measure. A positive dose-response was seen for both active drugs with meclofenamate 100 mg and ibuprofen 400 mg exhibiting the greatest efficacy for pain relief, pain reduction, time to remedication, and overall evaluation. Side effects were reported by 26 patients. They were evenly distributed among treatment groups with headache and drowsiness being the most common. During the multidose phase, there were only small differences in efficacy measures among active treatment groups. However, meclofenamate produced a higher incidence of stomach cramps and diarrhea than did ibuprofen (8.8% and 7.2% versus 0.8% and 0.8%). This study indicates that higher doses of nonsteroidal anti-inflammatory drugs are most effective immediately after surgery and that lower doses of these drugs can be used after the first postoperative day. The side effect profile of nonsteroidal anti-inflammatory analgesics is best observed with the use of a multidose study design.

The role of occupational therapy in a health maintenance program for pulmonary transplant candidates

This article describes an intervention model for occupational therapists who treat individuals awaiting pulmonary transplantation. Supportive occupational therapy interventions aimed at helping patients cope with the physical and psychosocial stresses that impede functional performance are described. Psychosocial and physical indicators of the functional status of pulmonary transplant candidates that may be amenable to occupational therapy intervention are identified. Treatment issues related to occupational therapy are presented and implications for occupational therapy research are suggested. The model may also be applied to patient populations having chronic, debilitating illnesses.

DNA in situ sensitivity to denaturation in bladder cancer and its correlation with tumor stage

DNA content and sensitivity of DNA in situ to denaturation by acid were analyzed by flow cytometry of cell nuclei freshly isolated from the bladder tumors of 32 patients and were compared with normal urothelium of 8 subjects. DNA sensitivity to denaturation was assessed in RNase treated cells by acridine orange metachromasia following partial denaturation with hydrochloric acid; the extent of denatured DNA is given as an index (alpha t), representing the ratio of single stranded to total DNA per nucleus. Of the low stage tumors (papillomas, Ta, Tis, T1) 11 of 18 (61%) were aneuploid. Of the high stage tumors (T2 and T3a) 11 of 14 (79%) were aneuploid. DNA in nuclei of normal transitional epithelium was very sensitive to denaturation, as was papilloma, characterized by nuclear alpha t indices of 0.73 +/- 0.01 (SD) and 0.73 +/- 0.04, respectively. Nuclear DNA of noninvasive carcinomas (Ta, Tis) was significantly more resistant to denaturation (alpha t = 0.69), and DNA of invasive carcinomas was most resistant, ranging from alpha t = 0.61 (T1 tumors) to alpha t = 0.59 (T2 tumors) to alpha t = 0.57 (T3 tumors). High stage tumors as a group (T2, T3) had significantly different (lower) alpha t values than low stage tumors (Ta, Tis, T1). In model cell culture systems it is known that a decrease in alpha t index, i.e., greater resistance to denaturability, occurs as cells transit from resting phase into the cell cycle. Whether the alpha t index can be used to estimate resting vesus cycling cells of human tumors is still speculative; changes in DNA denaturability also are known to occur with changes in chromatin structure during cell differentiation and in transformation. However, the empirical relationship between alpha t index and tumor stage, of itself, may prove clinically useful in identifying more advanced and perhaps more aggressive tumors.

Loss of motivation for speaking with bilateral lacunes in the anterior limb of the internal capsule

A 76-year-old man suddenly presented with loss of motivation for speaking. He had no aphasia, depression or dementia, but he did not want to speak with other people. CT scan showed hypodensities, presumably lacunes, mainly in the anterior limb of the two internal capsules. Global behavioral changes with loss of self psychic activation have been reported, but in our patient the disturbance was restricted to oral language. The role of activating cortico-subcortical loops is discussed.

[18 and one-half years' survival after cardiac graft. Clinical course and anatomical findings]

Operated upon in November, 1968, the last survivor of heart transplant recipients in those times has died on May 11, 1987, having survived 18 years and 6 months. The active life of this patient, however, was marred by episodes of graft rejection during the first post-operative years and by various incidents. It was mainly the complications of the immunosuppressive treatment that hampered his activities (osteoporosis) and provoked his death. Post-mortem examination confirmed that the heart was in good condition, found an active bronchial epithelioma and revealed iatrogenic lesions, namely adenomas, adenocarcinoma of the kidney and "regenerative" nodular hyperplasia of the liver with portal hypertension. Such lesions are observed in patients under long-term treatment with immunosuppressants. A "sleep apnoea" syndrome might have accounted for the formation of pulmonary hypertension lesions. The authors wish to pay their respects to this man who devoted himself to the service of other men.

[Dexamethasone suppression test in psychiatric pathology]

The dexamethasone suppression test (DST) has been used in psychiatric pathology for about 10 years. Carroll et al. consider this test to be specific of endogenous depression. According to these, and many other authors, approximately 55% of patients with endogenous depression show a positive response to the test, whereas a positive response is observed in only 4% of normal subjects or patients with psychiatric disorders other than major depressive disorders. The DST was performed in 162 psychiatric inpatients (5 with organic disease, 28 with schizophrenic disorders, 17 with major affective disorders, 5 with obsessive compulsive disorders, 103 with dysthymic disorders and 4 unclassified). Dexamethasone (1 mg) was administered orally at 11 p.m., and plasma cortisol concentration was measured the following day at 16 p.m. Response to the test was positive in 53% of patients with major affective disorders, 25% of those with schizophrenic disorders, 60% with obsessive compulsive disorders and 18% with dysthymic disorders. There was no statistical difference in the results according to age, sex ratio, family history of depression or duration of the disorders. Only two variables were close to the P less than 0.05 level of statistical significance: severity of the disorders and early morning awakening. DST sensitivity, therefore, would appear to be about 50% in major affective disorders, but this test is not specific as it may also be positive in other psychiatric disorders. A positive dexamethasone suppression test may be regarded as a sign of severity of psychiatric disorders.

[Occurrence of tardive dyskinesia during neuroleptic treatment]

The incidence of tardive dyskinesia under neuroleptic treatment is diversely estimated. The effectiveness of anticholinergics in its prevention is under discussion. Among 52 patients treated with neuroleptics for more than 5 years (mean: 9 years) only 2 developed tardive dyskinesia, and the disorder was transient in each case. The low doses of neuroleptic drugs administered and their systematic association with anticholinergics seem to be partly responsible for this low incidence of tardive dyskinesia.

[Plea for monoamine oxidase inhibitors. Retrospective study of 350 cases]

The case-records of 350 outpatients treated with monoamine oxidase inhibitors have been reviewed. All patients presented with depression, obsessions or phobias. About two-thirds benefited from the drugs, particularly after other treatments (including psychotropic drugs, seismotherapy, psychotherapy and internment) had failed. With the moderate doses administered (iproniazide: 50 mg/day; nialamide: 100 mg/day) side-effects were uncommon and mild and no incident was noted in 32 general anaesthesias given for surgical operations. These findings should help in lifting the ban on this category of drugs. Monoamine oxidase inhibitors are effective, useful and sometimes indispensable after failure of other antidepressants.

[Parkinson's disease. Retrospective study of 302 clinical case records]

This retrospective study of the case-records of 302 patients with Parkinson's disease shows that the condition begins earlier in males and that loss of weight during the first years of the disease is of poor prognosis. It also provides some arguments in favour of low-dosage L-dopa and suggests that no time should be wasted in administering this treatment.

Neoplastic tracheal stenosis

Primary tracheal tumors (PTT) are relatively rare and their diagnosis often late because the symptomatology is noncharacteristic and the signs only appear when over 60% of the lumen is obstructed. The most frequent histologic type is epithelioma (50 to 60%), but the glandular type which has a low malignant potential constitutes 25% to 40% of PTT, especially cystic adenoid carcinoma (cylindroma), which has a slow development but widely infiltrates the submucosa, distant from the macroscopic limits of the tumor. True benign tumors are rare. It is very important to know the tumor dimensions, and radiology is the best means of diagnosis in suspect cases. The usual treatment is surgery alone or associated with radiotherapy. The surgical techniques are now well-known and the operative mortality is very low when the indications are good. Excellent long-term results have been obtained with benign tumors, poor results, but sometimes with long palliation, in cases of epithelioma, and good results in cases of recurrent cylindroma. Statistics are, however, unavailable due to the fact that there is no large and homogeneous series.

[Clinical and radiological findings in 203 cases of delayed resorption of pulmonary fluid (author's transl)]

Among 1 186 neonates admitted consecutively to the Post-Royal intensive care Unit, 203 had respiratory distress, a chest roentgenogram typical of delayed resorption of lung fluid, and no other findings. Mean gestational age (GA) was 33 weeks and mean birth-weight (BW) was 1 948 g. Hood oxygen alone was used in 129 cases and intubation-ventilation-PEEP in 74 cases (46 of which were intubated before admission). The occurrence of radiological features was similar in ventilated and non-ventilated neonates : ground-glass pattern (70-80% of the cases), increased vascular markings (70-76%) enlarged right fissure (45%), thin lateral pleural density (24%) and normal cardio-thoracic ratio. The analysis of other prognostic factors showed that ventilated neonates had a significantly lower birth weight (1 689 g versus 2 097 g) and a significantly younger gestational age (31.9 versus 33.6). The study of DAa02 in non-ventilated neonates demonstrated wide individual variations, and the possibility of an early normal DAa02 but also of a late abnormal DAa02, with the associated risks of early hyperoxia or prolonged oxygen needs. In ventilated neonates, the mean duration of intubation was 4 days 13 hours; this duration decreased as the birth-weight rose. In view of the major role of BW and GA, the Port-Royal team advocates the direct admission to a neonatal intensive care unit of neonates with delayed resorption of lung fluid and a BW under 2 000 g. In this way, Pa02 can be closely monitored and artificial ventilation is readily available.