Trash feet after coronary angiography

Cholesterol crystal embolisation is a frequently underdiagnosed condition. While coronary catheterisation is safe and commonly performed, the reported patient developed very painful trash feet after undergoing this routine procedure. Ulceration and gangrene occurred after catheter manipulation during cardiac angiography, which caused occlusion of the small arteries in his feet. The triad of pain, livedo reticularis, and intact peripheral pulses is pathognomonic for cholesterol embolisation. The prognosis depends on the extent of the systemic disease and a high rate of mortality (75-80%) is observed. Prognosis is poor and the treatment is only supportive. It is suggested that while cardiac catheterisation is largely safe and a very commonly performed procedure, it can still lead to complications with serious side effects and can even prove fatal.

Congenital hearing impairment associated with rubella: lessons from Bangladesh

Infection with rubella virus during pregnancy may cause fetal death or the multiple congenital fetal abnormalities that are known as congenital rubella syndrome (CRS). Studies have demonstrated that congenital hearing impairment is the most frequent abnormality associated with intrauterine rubella infection. In the present study, the first of its kind in Bangladesh, we investigated the presence of rubella antibody in hearing-impaired children in order to understand the possible role of rubella infection in the development of hearing impairment. A total of 198 hearing-impaired children and 200 children without hearing problems were studied. After taking a detailed history from the parents, blood samples were collected from both mothers and children; sera were subjected to enzyme-linked immunosorbent assay (ELISA) for anti-rubella IgG. Rubella antibody was detected in 74% of the hearing-impaired children and in 18% of those with normal hearing: this finding correlated with the presence of rubella antibody in the mothers (67%) of rubella seropositive hearing-impaired children. In contrast, we observed rubella antibody in only 14% of the mothers of the children without hearing problems. Consistent with the presence of antibody, 41% of the seropositive mothers who had hearing-impaired children gave a history of fever and rash during early pregnancy. Our study indicates a strong association between rubella infection and hearing impairment in Bangladeshi children. In addition, it also indicates that infection by rubella virus is common in Bangladesh: this suggests that priority should be given to implementing appropriate measures for the control of rubella.

Connective tissue structures in clubfoot: a morphologic study

A morphologic study of connective tissue structures in clubfoot, with special emphasis on the presence of myofibroblasts, was undertaken to investigate the theory of retracting fibrosis as an etiologic factor. Nine idiopathic clubfeet from six patients were studied. Specimens from the medial and lateral capsule, medial and lateral fascia, spring and lacinate ligaments, and flexor digitorum longus, flexor hallucis longus, posterior tibialis, and Achilles tendon sheaths were investigated. Fifty specimens were examined using light microscopy and hematoxylin and eosin staining, and 26 were examined by transmission electron microscopy. Light microscopy failed to reveal any myofibroblast-like cells or any qualitative differences between specimens from capsule, fascia, ligaments, and tendon sheath. Using transmission electron microscopy, the authors identified two cell types: fibroblasts and mast cells. Some fibroblasts contained a network of microfilaments but all lacked microbundles, basal lamina, or plasmalemmal attachment plaques seen in typical myofibroblasts. Mast cells were rarely identified in capsular specimens. The absence of myofibroblast-like cells or typical myofibroblasts in clubfoot connective tissue structures does not support the theory of retracting fibrosis as a likely cause of contracture in idiopathic clubfoot.

Treatment of severe theophylline toxicity with hemodialysis in a preterm neonate

Theophylline, a drug frequently used to treat apnea of prematurity, has a prolonged half-life of 30 h in neonates. Severe overdoses of theophylline have an associated 10% mortality and significant morbidity. We describe a 1,220-g neonate who developed status epilepticus due to a theophylline overdose. Hemodialysis was instituted to increase elimination of theophylline. The patient tolerated the procedure without complication. The half-life of theophylline was 0.7 h during dialysis. No reported therapies used in neonates have achieved this magnitude of clearance. In fact, the clearance of theophylline in this neonate approached that obtained with hemoperfusion, the standard therapy for theophylline overdose in adult patients. This case demonstrates that hemodialysis is a safe and effective means of enhancing theophylline elimination for neonatal theophylline overdose.

Four new flavones and a new isoflavone from Iris bungei

Four new irisflavones A-D (1-4) and irilin D (5) have been isolated from the underground parts of Iris bungei along with known isoflavones, irilins A-B (6-7) and tlatancuayin (8). The structures of the new compounds were determined using NMR and mass spectroscopic methods and were found to be 2',5,7-trihydroxy-3,6-dimethoxyflavone (1), 2',5-dihydroxy-3,6,7-trimethoxyflavone (2), 2',5,6'-trihydroxy-3,6,7-trimethoxyflavone (3), 3,3',5-trihydroxy-2',7-dimethoxyflavone (4), and 3',4',5,7-tetrahydroxy-6-methoxyisoflavone (5). The structures of irisflavones 1, 3, and 4 were confirmed by single-crystal X-ray diffraction studies.

Monopolar radiofrequency energy for arthroscopic treatment of shoulder instability in the athlete

Monopolar radiofrequency energy is increasingly being used in the treatment of shoulder instability. Basic science studies and early clinical results have shown that application of thermal energy can result in successful shrinkage of the shoulder capsule. This procedure is useful in treating certain traumatic and recurrent instability conditions of the shoulder especially in the athlete where range of motion is preserved, recovery is faster than with open procedures, and there, is little disruption or alteration of inherent anatomy. The procedure is technically easy to perform, and the complication rate is low. Success, however, depends on proper patient selection, attention to the rehabilitation program, and patient compliance. Long-term follow-up will be necessary to determine if results for this procedure will deteriorate over time, especially in patients with multidirectional instability.

Management of symptomatic ureteric stumps laparoscopically

AIM

To study the advantage of excision of the distal symptomatic ureteric stumps with the retroperitoneal laparoscopic approach.

METHODS

Four patients who had failed to settle their symptoms with the initial conservative management were included in the study. All underwent excision of the distal symptomatic ureteric stumps with the retroperitoneal laparoscopic approach and then received prophylactic antibiotics.

RESULTS

We have achieved better results than those reported in the literature in terms of operating time (mean 1 h 45 min), blood loss (< 10 mL), postoperative recovery (within 12 h) and hospital stay (< 48 h).

CONCLUSION

Retroperitoneal laparoscopic excision is a safe, simple and effective method in the management of symptomatic ureteric stumps.

Reduced osmolarity oral rehydration solution for persistent diarrhea in infants: a randomized controlled clinical trial

OBJECTIVE

We evaluated and compared the efficacy of the World Health Organization (WHO) oral rehydration solution (ORS) and 2 different formulations of reduced osmolarity ORSs in infants with persistent diarrhea.

STUDY DESIGN

Infants with persistent diarrhea (n = 95) were randomized to 1 of the 3 ORSs: WHO-ORS (control, n = 32), a glucose-based reduced osmolarity ORS (RORS-G, n = 30), or a rice-based reduced osmolarity ORS (RORS-R, n = 31) for replacement of ongoing stool losses for up to 7 days. Major outcome measures were stool volume and frequency, ORS intake, and resolution of diarrhea.

RESULTS

Although there were variations from one study day to another, the stool volume was approximately 40% less in the reduced osmolarity ORS groups; consequently, these children required less ORS (22% for RORS-G and 27% for RORS-R groups). A higher proportion of children in the RORS-R groups also had resolution of diarrhea during the study period. No children in any of the treatment groups had hyponatremia.

CONCLUSION

Reduced osmolarity ORS is clinically more effective than WHO-ORS and may thus be advantageous for use in the treatment of children with persistent diarrhea.

Two new aurones from marine brown alga Spatoglossum variabile

Two new aurones, 4'-chloro-2-hydroxyaurone (1) and 4'-chloroaurone (2) were isolated from Spatoglossum variabile. The structures of these compounds were elucidated by modern spectroscopic techniques.

N-methyl-D-aspartate receptor subunit NR2B is widely expressed throughout the rat diencephalon: an immunohistochemical study

Glutamate (Glu), a major excitatory neurotransmitter within the hypothalamus and thalamus, acts upon many receptors, including the N-methyl-D-aspartate (NMDA) subtype. Abundant evidence suggests that variations in the subunit composition of NMDA receptors (NMDA-Rs) contribute to differences in Glu's immediate electrophysiological effects as well as to the patterns of signal transduction cascades it triggers to mediate long-term changes in neuronal function. We have previously shown that hypothalamic NMDA-Rs containing the NR2B subunit may be involved in the control of eating as well as in the mediation of physiological responses to osmotic stimuli. To broaden our understanding of diencephalic NMDA-R participation in other functions, we localized the NR2B subunit in the diencephalon of the adult male rat using immunoperoxidase, immunogold, and immunofluorescence techniques and an affinity-purified polyclonal antibody specific for the NR2B subunit of the NMDA-R. In addition, we used a monoclonal NR2B antibody with immunoperoxidase detection to confirm the NR2B distribution seen with the polyclonal antibody. In the hypothalamus, the highest levels of NR2B immunoreactivity (-ir) were found in the magnocellular neurosecretory system, including the paraventricular and supraoptic nuclei. A new finding was that intense NR2B-ir was present within perivascular "accessory" magnocellular groups of this system, including the nucleus circularis, anterior fornical nucleus, and scattered clusters of lateral hypothalamic cells apposed to blood vessels. Robust NR2B-ir was also present within the arcuate nucleus, the median eminence, and the tuberal nucleus, and light immunostaining was found in all other hypothalamic nuclei examined. In the thalamus, the highest NR2B-ir was observed in the medial habenula and the anterodorsal, paraventricular, rhomboid, reticular, and dorsal lateral geniculate nuclei. As in the hypothalamus, all thalamic nuclei examined displayed at least light immunostaining for this subunit. Control sections, including those incubated with the polyclonal NR2B antibody preadsorbed with its fusion protein, were virtually devoid of immunostaining. This demonstration that the NR2B subunit of the NMDA-R is widely distributed in the diencephalon, implicates it in a wide variety of functions, and provides a useful anatomical framework for establishing a comprehensive map of Glu receptor populations within this major subdivision of the brain.

Hyposplenism from Mycobacterium avium complex infection in a patient with AIDS and immune thrombocytopenia

We describe a patient with HIV-related immune thrombocytopenic purpura with known Mycobacterium avium complex (MAC) infection presenting with intracerebral hemorrhage associated with severe thrombocytopenia who failed splenectomy following unsuccessful trials of corticosteroids and intravenous immunoglobulin. His presplenectomy peripheral blood smear showed Howell-Jolly bodies and microscopic examination of his spleen demonstrated multiple granulomas with numerous acid-fast organisms replacing the normal splenic tissue. We postulate that splenic hypofunction secondary to overwhelming MAC infection contributed to the failure of the thrombocytopenia to promptly respond to splenectomy.

A prospective randomized placebo-controlled double-blinded pilot study of misoprostol rectal suppositories in the prevention of acute and chronic radiation proctitis symptoms in prostate cancer patients

OBJECTIVE

Radiation proctitis is a known complication of radiation therapy for prostate cancer. Available medical treatment is usually ineffective and has focused on relieving symptoms after damage has occurred. Our study aimed at evaluating the use of misoprostol rectal suppositories in the prevention of acute as well as chronic radiation proctitis symptoms.

METHODS

A prospective, randomized, placebo-controlled, double-blinded trial was conducted in patients with recently diagnosed stages B and C prostate cancer who underwent external beam irradiation. Patients received either a misoprostol or a placebo suppository 1 h before each radiation session. Misoprostol suppositories were made from two 200-microg tablets (Cytotec, Searle Pharmaceuticals, Skokie, IL), whereas the placebo was made from cocoa butter. A 12-point radiation proctitis symptom score was obtained from each patient at 4, 8, 12, and 36 wk after radiation therapy.

RESULTS

A total of 16 patients were enrolled. Seven patients received placebo, and nine patients received misoprostol. Mean radiation proctitis symptom scores in the placebo group were 4.86, 5.86, 5.71, and 3.83 at 4, 8, 12, and 36 wk, respectively. The mean scores in the misoprostol group were 0.78, 0.67, 0.33, and 0.37 at 4, 8, 12, and 36 wk, respectively. The difference between the two groups was statistically significant (p < 0.05) at 4, 8, 12, and 36 wk.

CONCLUSION

Misoprostol rectal suppositories significantly reduce acute and chronic radiation proctitis symptoms in patients receiving radiation therapy for prostate cancer.

Percutaneous nephropexy

OBJECTIVE

The authors present a 12-year (1986-98) study of a new procedure called percutaneous nephropexy (PCNP). This procedure was performed on 51 renal ptosis patients at two urological departments (in Pakistan and Hungary) with satisfactory results. The idea for PCNP was adapted from the observation that after drain insertion following nephrostomy a scar is quite sufficient to hold the kidney in place. That idea was used to fix the kidney at the required level.

MATERIAL AND METHODS

Thirteen patients complained of a palpable mobile mass in the abdomen while others suffered from pain in their affected flank with recurrent attacks of urinary tract infection. On ultrasonic examination the kidney was found to be lower than the normal position. This observation was confirmed by a standing intravenous urography (IVU) examination that also showed a tortuous ureter. Nine patients also had a stone in the affected kidney. The operation involved puncture and dilatation of a channel through the lower calyx.

RESULTS

Control IVU examination was performed after wound healing and was repeated 2 months after the operation, followed by consecutive ultrasonic examinations. Standing X-ray films obtained after contrast material injection showed the kidney to be at a higher level with a straight ureter. Forty-five patients (88.2%) recovered completely.

CONCLUSION

In the authors' opinion PCNP is a good alternative to open nephropexy operations in renal ptosis cases, particularly when laparoscopic surgery facilities are not available. Although PCNP was developed in circumstances in which the availability of equipment was restricted, in terms of benefits it is comparable with laparoscopic nephropexy.

Medial displacement of grommets: an unwanted sequel of grommet insertion

Grommet insertion is one of the commonest surgical procedures performed in the UK. We have come across three cases in which grommets have displaced medially in the middle ear after establishing a satisfactory post-insertion position. We suggest that an abnormally long myringotomy incision and improper placement of the grommet are responsible for this unwanted outcome.

Screening colonoscopy in asymptomatic average-risk African Americans

BACKGROUND

Recent data indicate that colorectal cancer incidence and mortality in white Americans have been declining since 1985 at a rate of 2% to 3% per year. In African Americans, however, mortality from colorectal cancer appears to be increasing. We sought to evaluate the prevalence of colonic neoplasia in asymptomatic African Americans.

METHODS

We performed a cross-sectional colonoscopy screening study to determine the prevalence of colonic neoplasia in asymptomatic African Americans older than 50 years of age.

RESULTS

One hundred sixty-six subjects were evaluated for the study of whom 121 (69 women) were deemed to be asymptomatic average-risk persons and completed colonoscopy. Forty-two individuals (35%) had a total of 72 adenomas (67 tubular and 5 tubulovillous); 47 (65.3%) of these were proximal to the splenic flexure. Three subjects had an adenoma 1 cm or greater in diameter and none had severe dysplasia.

CONCLUSIONS

The overall prevalence of adenomas in asymptomatic average-risk African Americans was comparable to that of previously described populations. The predominance of right-sided adenomas in this study confirms previous findings and is an area requiring further study. Until this issue is resolved, we suggest the use of colonoscopy rather than sigmoidoscopy for screening for colorectal neoplasia in asymptomatic, average-risk African Americans.

Reversible granulocytopenia in association with riluzole therapy

OBJECTIVE

To report a case of severe neutropenia developing in association with riluzole 200 mg/d.

CASE SUMMARY

A 63-year-old woman with amyotrophic lateral sclerosis (ALS) presented with nausea, anorexia, and fever two weeks following inadvertent dose escalation of riluzole from 100 to 200 mg/d. Granulocytopenia was diagnosed and evaluation for a possible causative infectious process was negative; riluzole was considered a possible offender. Blood counts returned to normal with discontinuation of riluzole and administration of filgramstim.

DISCUSSION

Riluzole is a glutamate release inhibitor used in the treatment of ALS, a devastating, progressive neurodegenerative disorder affecting motor neurons. A variety of adverse effects have been described with riluzole therapy, most commonly dizziness and gastrointestinal disorders. In this patient, multiple investigations failed to reveal an infectious cause or other drug-induced cause for the granulocytopenia.

CONCLUSIONS

Granulocytopenia has been reported as an adverse effect of riluzole but is not a complication well known to clinicians, and there are no detailed reports published in the literature. In this patient, several lines of evidence raise the possibility of a causal relationship between riluzole and granulocytopenia.

Dose-intense paclitaxel, etoposide and cyclophosphamide: a safe and active regimen for tumor cytoreduction and stem cell mobilization in metastatic breast cancer

Patients with metastatic breast cancer in complete remission are the ones most likely to have an improved outcome with subsequent high-dose chemotherapy and autologous peripheral blood stem cell transplantation (HDC-PBSCT). Peripheral blood stem cells are usually procured following mobilization with single agent chemotherapy and colony-stimulating factor support. We utilized a dose-intense regimen of paclitaxel 200 mg/m2 i.v., etoposide 60 mg/kg i.v., and cyclophosphamide 3 g/m2 i.v. (TEC) followed by daily administration of granulocyte colony-stimulating factor. The aim was not only to mobilize stem cells but also to achieve optimal tumor cytoreduction prior to HDC/PBSCT. One hundred consecutive patients with metastatic breast cancer received 257 cycles of TEC between March 1994 and June 1997, with the aim of collecting 5 x 106 CD34-positive cells/kg usually following the second cycle of chemotherapy. Patient characteristics included a median age of 45 years, a median of two organ systems involved by disease, a median of two prior chemotherapy regimens and eight prior chemotherapy cycles, and a median interval of 8 months from diagnosis of metastases to first cycle of TEC. There were 61 febrile episodes during neutropenia and 13 of these were associated with bacteremia or fungemia. Mortality rate was 1%. An adequate number of stem cells was collected in 90% of patients. The overall response rate of the tumor was 58.8% with 23.7% complete responders among 97 evaluable patients. Multivariate analysis demonstrated chemosensitivity to the most recent standard chemotherapy regimen administered for metastatic disease, an ECOG performance score of 0 as opposed to 1, 2 or 3, and involvement by disease of only one organ system as significant variables for achieving a complete remission with TEC. This novel dose-intense regimen was safe and well tolerated, highly active against metastatic breast cancer, and capable of excellent stem cell mobilization. Bone Marrow Transplantation (2000) 25, 123-130.

Effects of dexamethasone on meconium aspiration syndrome in newborn piglets

We examined the effects of dexamethasone on lung function in a piglet model of meconium aspiration syndrome. We induced lung injury in 10 newborn piglets (age 5 +/- 0.2 d) with 4 mL/kg body weight of 20% sterile human meconium in normal saline given via tracheostomy. Ventilator management was aimed at maintaining comparable values of end tidal carbon dioxide, Hb saturation, and arterial blood gases. Lung function was assessed using a BICORE CP100 neonatal monitor. Five piglets received 0.5 mg/kg of dexamethasone 2 and 8 h after meconium administration, whereas control piglets received normal saline at similar times. Ventilator settings, oxygen requirements, and lung compliance were similar between groups at the start of the study. Two hours after the instillation of meconium, there was marked lung dysfunction in both groups as evidenced by increased oxygen requirements [fraction of inspired oxygen (FiO2) 0.98 +/- 0.01 versus FiO2 0.21 +/- 0, p < 0.0001] and reduced lung compliance (0.35 +/- 0.03 versus 0.8 +/- 0.03 mL x kg(-1) x cm(-1) H2O, p < 0.0001). Administration of dexamethasone resulted in lower oxygen requirements (FiO2 0.27 +/- 0.01 versus FiO2 1.0 +/- 0.0, p < 0.00001), lower oxygenation index (2.17 +/- 0.17 versus 22.64 +/- 3.39, p < 0.0001), ventilatory efficiency index (0.30 +/- 0.01 versus 0.07 +/- 0.01, p < 0.0001), and improved lung compliance (0.68 +/- 0.04 versus 0.34 +/- 0.05 mL x kg(-1) x cm(-1) H2O, p < 0.001) compared with the control group. In summary, a two-dose course of 0.5 mg/kg of dexamethasone improved blood gases and lung function in a piglet model of meconium aspiration syndrome.

Lymphatic filariasis in two distinct communities of upper Assam

Current status of bancroftian filariasis among two distinct communities of Upper Assam was evaluated. High prevalence (10.3% mf rate) in tea workers descendents of tribals migrated from endemic states such as Orissa, Bengal, Uttar Pradesh and southern states of India, were recorded. Among non tea workers (indigenous population) significantly low mf rate was found in spite of the fact that both the communities are living in close vicinity and in similar ecological and mosquitogenic conditions. Culex quinquefasciatus was incriminated as vector in the areas of both the communities. A group of recent migrants of Bihar and Bengal living in the locality of non tea worker population were also found microfilaraemic. Significantly lower infection rate in non tea worker population appears to be associated with host susceptibility to the infection. Familial clustering in microfilaraemic subjects noticed in tea workers group also suggests involvement of racial susceptibility to infection.