Idiopathic intracranial hypertension. A prospective study of 50 patients

Management of patients with idiopathic intracranial hypertension (IIH) should be based on the presence and progression of visual loss. To characterize the clinical course of IIH more completely, we monitored the clinical status, especially visual function, in 50 consecutive newly-diagnosed patients over a period of 2 to 39 months (average follow-up 12.4 months). The mean age at onset of symptoms was 31 (range 11-58) yrs; 46 (92%) were women and 47 (94%) were obese (mean weight 90 kg). Common symptoms were headache (92%), transient visual obscurations (72%) and intracranial noises (60%); 13 of the patients (26%) initially had complaints of sustained visual loss. There was visual loss as determined by Goldmann perimetry in 96% and by automated perimetry in 92%. Contrast sensitivity testing was abnormal in 50% and Snellen acuity in 22%. Two patients (4%) became blind in both eyes. The Goldmann visual field grade improved in 60% of patients but visual function deteriorated in 5 (10%). Deterioration of visual field grade was significantly associated only with weight gain during the year before diagnosis. Visual loss in patients with IIH is common and is often reversible. Patients should be evaluated by perimetry using an appropriate strategy and contrast sensitivity testing, along with careful examination of the optic discs.

Bleeding time prolongation with streptokinase and its reduction with 1-desamino-8-D-arginine vasopressin

The mechanism by which treatment with thrombolytic agents causes bleeding is not known. Recently, frequency of bleeding events has been shown to correlate with bleeding time, particularly in individuals treated with aspirin. We examined the effects of streptokinase (20,000-60,000 IU/kg) on bleeding time in 40 rabbits pretreated with aspirin, a model for fibrinolytic therapy. We then tested the effects of 1-desamino-8-D-arginine vasopressin (DDAVP) (0.3 microgram/kg), an agent known to reduce bleeding time in a variety of bleeding disorders, in 20 rabbits and compared the results with those of a control group of rabbits receiving normal saline placebo. Aspirin increased the bleeding time from a baseline mean +/- SEM value of 119 +/- 15 to 191 +/- 34 seconds in the control group and from 114 +/- 6 to 188 +/- 18 seconds in the experimental group. The addition of streptokinase increased the bleeding time to 592 +/- 119 seconds in the control group and 810 +/- 114 seconds in the experimental group (p = NS). Subsequent infusion of DDAVP decreased the bleeding time in the experimental group to 302 +/- 29 seconds (p less than 0.01 versus streptokinase) compared with 572 +/- 79 seconds (p = NS versus streptokinase) in the control animals given saline placebo. In a subset of rabbits receiving aspirin and streptokinase (40,000-60,000 IU/kg), samples were obtained for platelet aggregation (n = 16), von Willebrand factor antigen concentration (n = 17), and von Willebrand factor multimer distribution (n = 14). Maximal rates of ADP-induced platelet aggregation were not affected by DDAVP infusion, nor was the plasma concentration of von Willebrand factor antigen, quantified by an immunoradiometric assay, significantly affected by DDAVP infusion. Furthermore, the von Willebrand factor multimer ratio decreased with DDAVP administration. These findings indicate that aspirin and streptokinase combined result in a marked increase in bleeding time that can be reduced by DDAVP. This effect of DDAVP is not accompanied by an increase in platelet aggregation response, plasma von Willebrand factor antigen concentration, or von Willebrand factor multimer ratio.

Inhibition of fibrinogen binding to human platelets by S-nitroso-N-acetylcysteine

Because of the central role of fibrinogen binding in platelet aggregation and recent evidence implicating S-nitrosothiol compounds in the platelet inhibitory effects of endogenous and exogenous organic nitrate compounds, we examined the effect of the S-nitrosothiol S-nitroso-N-acetylcysteine (SNOAC) on fibrinogen binding to gel-filtered human platelets. We found that SNOAC markedly inhibited the binding of fibrinogen to normal human platelets in a dose-dependent fashion and that this inhibitory effect was the result of both an increase in the apparent Kd of the platelet receptor for the fibrinogen molecule (from 6.8 x 10(-7) to 1.8 x 10(-6) M, a 2.7-fold increase) and a decrease in the total number of fibrinogen molecules bound to the platelet (from 76,200 to 38,250, a 50% decrease). In addition, we noted a rapid, dose-dependent rise in platelet cyclic GMP levels following exposure of platelets to SNOAC which was significantly inversely correlated with fibrinogen binding and was accompanied by inhibition of intracellular calcium flux in response to a variety of platelet agonists. Similar dose-dependent inhibition of fibrinogen binding was found in the presence of cyclic GMP analogues and was significantly enhanced by inhibition of platelet cyclic GMP phosphodiesterase. These results describe the inhibition of platelet fibrinogen binding by an S-nitrosothiol compound, help define the biochemical mechanism by which S-nitrosothiols inhibit platelet aggregation, and lend support to the view that cyclic GMP is an important inhibitory intracellular mediator in human platelets.

Temporal effects of thrombolytic agents on platelet function in vivo and their modulation by prostaglandins

To examine the temporal effects of plasmin generated in vivo on platelet function, we infused tissue-type plasminogen activator (t-PA) in rabbits over 3 hours and measured ex vivo platelet aggregation. We noted an initial increase in the aggregation response to ADP occurring 30 minutes after the start of infusion. This enhanced response was short-lived and by 180 minutes was reduced, compared with pretreatment levels. Baseline aggregation response was restored by 240 minutes. This pattern of aggregation response to t-PA infusion was also seen with thrombin as the agonist. Coinfusion of either prostaglandin I2 or prostaglandin E1 abolished the initial hyperaggregable phase induced by t-PA; the hypoaggregable phase occurred earlier (after 60 minutes) and persisted throughout the 1-hour recovery period. Similarly, streptokinase infused for 1 hour also increased platelet aggregation at early times and then reduced aggregation responses after the first hour. Plasma plasmin activity increased as expected with t-PA infusion alone, peaking at 30 minutes and returning to baseline by the first hour. Interestingly, prostaglandin E1 blunted the rise in plasma plasmin activity. This same dose of prostaglandin E1 or prostaglandin I2 used alone did not appreciably alter platelet function at any time during the experiment. Our data show that therapeutic doses of t-PA or streptokinase produce a biphasic effect on platelet aggregation response in the rabbit. Coinfusion of either of the antiplatelet agents, prostaglandin E1 or prostaglandin I2, abolishes the hyperaggregable phase and prolongs the inhibitory effects on platelet aggregation produced by t-PA. These data suggest that the effects of thrombolytic agents on platelet function are complex and can be modulated by antiplatelet prostaglandins.

Multicenter, randomized trial of ciprofloxacin plus azlocillin versus ceftazidime plus amikacin for empiric treatment of febrile neutropenic patients

In a multicenter, randomized clinical trial, the efficacy of ciprofloxacin plus azlocillin was compared with that of a standard regimen of ceftazidime plus amikacin for the initial empiric treatment of fever in neutropenic cancer patients. In addition, the efficacy of early conversion from intravenous therapy to orally administered ciprofloxacin was compared with that of continued ceftazidime plus amikacin. Seventy-one oncology patients with 79 episodes of fever and neutropenia were randomly assigned to receive initial empiric antibiotic therapy with either intravenously administered ciprofloxacin and azlocillin followed by orally administered ciprofloxacin (regimen 1, 25 episodes); ceftazidime and amikacin (regimen 2, 30 episodes); or ceftazidime and amikacin followed by oral ciprofloxacin (regimen 3, 24 episodes). Microbiologically documented infections were the cause of fever in 10 (40 percent), seven (23 percent), and nine (38 percent) episodes in regimens 1, 2, and 3, respectively, including six, five, and four episodes of bacteremia. Patient survival was 90 to 92 percent in each regimen; however, some modification of antimicrobial therapy occurred in 65, 44, and 41 percent of surviving patients in regimens 1, 2, and 3, respectively. The rate of clearance of initial bacteremia was 67 percent (four of six) in regimen 1, 100 percent (five of five) in regimen 2 and 50 percent (two of four) in regimen 3. Patients in regimens 1 and 3 were able to convert to orally administered ciprofloxacin in 32 (65 percent) of 49 episodes after a mean of six days of intravenous therapy. Superinfections occurred in 24, 10, and 12 percent of patients receiving regimens 1, 2, and 3, respectively, and occurred similarly for patients receiving orally administered ciprofloxacin, 12 percent (four of 32), and intravenous therapy, 17 percent (eight of 47). Parenteral ciprofloxacin was generally well tolerated. One (4 percent) of 25 patients receiving regimen 1 experienced oto- or nephrotoxicity, compared with eight (15 percent) of 54 patients receiving regimens 1, 2, and 3 (p = 0.15), including three patients who required premature termination of aminoglycoside therapy. Our data suggest that the combination of ciprofloxacin and azlocillin is an effective alternative to ceftazidime and amikacin for the initial empiric therapy of febrile neutropenic patients, is generally well tolerated, and avoids the oto- and nephrotoxicity associated with aminoglycoside use. In addition, a majority of patients could change to orally administered ciprofloxacin alone after six days of parenteral therapy.

The cytostatic effects of alpha-interferon may be mediated by transforming growth factor-beta

There is some evidence to suggest that transforming growth factor-beta (TGF-beta) mediates the cytostatic effects of the anti-oestrogen tamoxifen. In this study we have demonstrated that alpha-interferon has a significant anti-proliferative effect on the oestrogen receptor-positive human breast cancer cell line ZR-75. There is decreased phenotypic expression of the oestrogen receptors (to about 30% of control values) and increased TGF-beta mRNA. Under the growth conditions used here, ZR-75 cells had approximately 5800 TGF-beta binding sites per cell, with an apparent dissociation constant of 70 pm, and we have shown that the anti-proliferative effects of alpha-interferon can be reduced by 60% by co-treating the cells with a TGF-beta polyclonal antibody. The cytostatic effects of alpha-interferon may therefore be mediated by TGF-beta in this human breast cancer cell line.

Renal cirsoid arteriovenous malformation masquerading as neoplasia

A woman with renal colic and microscopic hematuria had filling defects in the left renal collecting system detected on excretory urography. A nephrectomy, performed because of suspected malignancy, might have been averted by renal angiography.

Diagnostic value of the history and examination in giant cell arteritis: a clinical pathological study of 81 temporal artery biopsies

To determine the value of the history and examination in predicting a temporal artery biopsy result, 81 temporal artery biopsies between 1974-1980 were studied. Each biopsy was scored blindly and independently by 2 pathologists and correlated with clinical data and the indications for biopsy at the time of the biopsy. Thirteen biopsies had giant cells and were considered positive, 8 had mononuclear inflammatory cells in the wall (7 cases) or healed arteritis (1 case) and were considered probable, and 60 were negative. In patients with an elevated sedimentation rate, the presence of a sign (tenderness or abnormal temporal artery), or a symptom (visual change or headache) predicted 18 of 21 (86%) positive-probable biopsies, but misclassified 32 of 60 negative biopsies. Attempts to derive a clinical decision rule with improved specificity resulted in unacceptably low sensitivity (missing 5 of 21 positive-probable biopsies). A minimum 5-year followup showed that those patients treated with steroids had a 6-fold increase in fractures and a 4-fold increase in cataracts.

Serum hormone levels in breast cancer patients and controls in Egypt and Great Britain. The Anglo-Egyptian Health Agreement Collaborative Study

The levels of serum prolactin, progesterone, oestradiol and sex hormone binding globulin (SHBG) have been measured in premenopausal and postmenopausal normal women and patients with breast cancer living in Egypt or Britain. In addition, the percentage of non-protein-bound oestradiol (free oestradiol) was determined. The breast cancer patients had attended the Tanta Cancer Institute, Cairo Cancer Institute, Guy's Hospital, London or the Western Infirmary, Glasgow. The respective control women were unaffected volunteers living in Tanta, Cairo, Guernsey or Glasgow. The concentration of serum prolactin, oestradiol and progesterone was similar for cancers and controls within, or between centres. There was no difference between patients and their respective controls in SHBG levels for the four centres. In premenopausal women a comparison of combined patient and control groups showed that women from Tanta had significantly raised SHBG levels compared with similarly combined groups from the other three centres. Egyptian women (cancers plus controls) had a higher percentage free oestradiol (1.61%) than British women (1.42%). In all four centres there was a significant linear correlation between the percentage free oestradiol and SHBG levels for pre- and postmenopausal women. The regression line for British women was significantly lower than that of Egyptian women. Thus, for a given serum SHBG level, Egyptian women have a higher free oestradiol than British women. The results may be associated with the claim that Egyptian women present with a more aggressive form of breast cancer than British women.

Cerebral malignant tumors with ependymal and choroidal differentiation in two siblings

Two siblings in a family without a history of phacomatosis or cerebral tumors developed malignant tumors in the posterior fossa at age 28 months and in the left cerebral hemisphere at age 15 months, respectively. Dual ependymal and choroid plexus epithelium differentiation was established by histological, ultrastructural, and immunocytochemical studies. The development of this rare tumor in siblings suggests an inherited predisposition, a common environmental insult, or both.

Retropharyngeal hematoma as a new cause of acute upper airway obstruction in rheumatoid arthritis

A patient with severe rheumatoid arthritis (RA) receiving chronic anticoagulation therapy developed acute life threatening airway obstruction. The source of obstruction was a retropharyngeal hematoma compressing the upper airway rather than acute laryngeal dysfunction from the patient's RA. Our case illustrates a new cause of acute stridor and airway obstruction in RA. Publications on upper airway obstruction in RA and airway obstruction secondary to retropharyngeal hematoma are discussed.

Ultrastructural morphology and cellular differentiation in acinic cell carcinoma

Acinic cell carcinomas, in some instances, contain a component of intercalated duct cells. However, the manner in which this element is integrated within the more obvious acinar cells, as well as the role neoplastic intercalated duct cells play in determining morphologic patterns in acinic cell tumors, has not been fully investigated. Ultrastructural study and immunostaining with antibodies to cytokeratins and to S-100 protein carried out in nine cases of parotid acinic cell carcinoma suggest two basic differentiation patterns. In three cases, the lesions were essentially composed of acinar cells (with variation in the number and form of secretory granules), and one of these tumors was unique in having ultrastructural evidence of differentiated myoepithelial cells. In the second group of six cases, there was light microscopic, ultrastructural, and immunohistochemical evidence of a significant component of intercalated duct cells. By means of both immunostaining (intercalated ducts were positive for keratin and S-100 protein; acinar cells were negative for both antigens) and electron microscopy, flattened-to-cuboidal intercalated duct cells were noted to enclose and, presumably, to be involved in the formation of microcystic spaces. Acinic cell carcinomas with a more solid growth pattern contained groups of intercalated duct cells positive for keratin and S-100 protein. Ultrastructurally, these cells were organized into well-formed ducts related to nests of acinar cells. Acinic cell carcinoma is another class of salivary gland tumor in which there can be an integrated proliferation of intercalated duct and acinar cells and, infrequently, of myoepithelial cells, all organized in a simulation of the intercalated duct-acinar unit of the normal salivary gland.

Visual loss in pseudotumor cerebri. Incidence and defects related to visual field strategy

Visual field examinations were performed serially on 20 patients with pseudotumor cerebri using a modified Armaly-Drance visual field strategy with a Goldmann perimeter as well as an automated perimeter (Octopus). Visual loss was found in 75% of eyes using the manual strategy and in 77.5% of eyes with automated threshold perimetry. This incidence of visual loss is 50% greater than any previously reported series. All major defects detected were present with both types of perimetry. Both strategies were more sensitive for documenting visual loss than previously described strategies. Since therapy for pseudotumor cerebri is determined by the degree and progression of visual loss, a specific sensitive strategy, rather than routine screening perimetry, should be used for determination of visual loss.

Evolution of karyotypic abnormalities and C-MYC oncogene amplification in human colonic carcinoma cell lines

Cell lines (COLO 320 DM and COLO 320 HSR), established from a human neuroendocrine tumor, contain an amplified cellular oncogene (c-myc). We have previously shown that the homogeneously staining regions (HSRs) of a marker chromosome in the COLO 320 HSR cells that evolved in culture from COLO 320 DM cells contain amplified c-myc. Molecular hybridization in situ has now been used to demonstrate that the HSRs are on both arms of what was once an X chromosome. We also show that amplified c-myc copies are present in the isolated double minute chromosomes (DMs) of the COLO 320 DM cells that were characteristic of the tumor cells initially established from the patient. The results suggest that the amplified c-myc appeared first as DMs and was subsequently transposed to engender HSRs on an X chromosome. The initial COLO 320 tumor cell may have acquired two "early replicating" (i.e., active) X chromosomes and lost the "late replicating" (i.e., inactive) X.

Subchromosomal localization of mouse IFN-alpha genes by in situ hybridization

We have utilized in situ hybridization techniques to determine the chromosomal location of alpha-interferon (IFN-alpha) genes in the mouse. The results allow regional assignment of the IFN-alpha gene family to a position close to the center of chromosome 4, in bands C3-C7.

The mode of action of ethyl lactate as a treatment for acne

We have shown that an alcoholic lotion containing ethyl lactate when applied topically to rat skin under occlusion became localized in the follicles and sebaceous glands. When applied to human facial skin the ethyl lactate was hydrolysed to ethanol and lactic acid, and thereby lowered the skin pH. Under such conditions the growth of recoverable skin bacteria, in particular the anaerobe Propionibacterium acnes, was inhibited, and the hydrolysis of sebum to free fatty acids by lipase derived from the bacteria was greatly impaired. These effects of ethyl lactate would account for its observed clinical efficacy in acne vulgaris.

Circadian breast skin temperature rhythms: overt and occult benign and occult primary malignant breast disease

Circadian variations of breast surface temperature have been measured in patients with overt or occult benign breast disease, or in those with occult breast cancer. Subjects were studied in a hospital ward environment well-controlled with respect to ambient temperature. Using manual techniques temperatures were recorded half-hourly for 96 hr from replicate sensors placed on quadrants of the left and right breasts inclusive of tumour areas and similar sites on the contralateral breast. Application of time series analysis failed to consistently demonstrate differences in values for the rhythm parameters for the tumour area and contralateral site. It was apparent, however, that the tumour area was generally associated with a reduced initial variance of the series in addition to a reduced percentage variance explained by a time series model with two rhythmic components when compared to the control site. These data suggest that efforts to identify early breast disease from signals of breast temperature should, at least, be directed to studies of temperature variance.

Saccular aortic aneurysm in an asymptomatic child

An asymptomatic boy was found to have coarctation of the thoracic aorta. Despite no history of endocarditis or trauma, a large saccular aneurysm involving the coarctation site was identified angiographically, confirmed, resected surgically, and examined histologically.

Corn syrup sugars: in vitro and in vivo digestibility and clinical tolerance in acute diarrhea of infancy

We evaluated the in vitro and in vivo digestibility and clinical tolerance of three corn syrup sugars (DE10, 15, 24) and one infant formula containing corn syrup sugar as the sole carbohydrate source (DE24). In vitro studies were conducted using human duodenal fluid and jejunal mucosa with normal enzyme activities. In vivo studies included intragastric perfusion studies and tolerance tests using the corn syrup sugars and a clinical formula trial in 32 infants with acute diarrhea. Results of the in vitro studies showed that each of the corn syrup sugars was well hydrolyzed by duodenal fluid and by mixtures of duodenal fluids and mucosal homogenates. Similarly, in vivo studies revealed significant hydrolysis in the proximal intestine, as measured during the perfusion studies, and adequate absorption, as indicated by a rise in serum glucose concentration during tolerance tests. Only patients who had a marginal serum glucose rise after a glucose meal had a blunted rise after a corn syrup feeding. More than 85% of the infants beginning the clinical trial tolerated the formula well and gained weight at or above the expected rate for age during the study interval. These data indicate that, except with severe mucosal injury and secondary monosaccharide intolerance, glucose polymers of the dextrose equivalents tested are suitable carbohydrate sources for infants recovering from acute diarrhea.

A cellular oncogene (c-Ki-ras) is amplified, overexpressed, and located within karyotypic abnormalities in mouse adrenocortical tumour cells

The cellular oncogene c-Ki-ras is amplified 30- to 60-fold in cells of the mouse adrenocortical tumour Y1. The amplified oncogene is located in double minute chromosomes and in a homogeneously staining chromosomal region, common karyotypical anomalies of tumour cells. The amounts of c-Ki-ras specific mRNA and of the protein (p21) encoded by the amplified gene are correspondingly elevated. Amplification and enhanced expression of cellular oncogenes may contribute to the genesis and/or maintenance of at least some naturally occurring tumours.

Quantitation of complement proteins in rheumatic disease

Complement proteins serve a critical function in the non-antigen-specific elimination of foreign substances and organisms and of immune complexes. Studies of genetic and acquired alterations of complement proteins have provided insights into the pathophysiology of a number of rheumatic diseases, especially those in which immune complexes are believed to have a role in pathogenesis. Complement levels may be helpful in the management of some patients with SLE or vasculitis, and in evaluation of synovial, pleural and pericardial fluids.

Effects of alternative techniques of low-dose heparin administration on hematoma formation

A small clinical trial was conducted to compare a modified subcutaneous injection technique with the standard subcutaneous method. The data in this study do not strongly support the use of either technique. However, the modified subcutaneous method may be preferable in that fewer injection-site hematomas formed. Further research with a larger population is indicated before either method can be recommended over the other.

Oestrogen receptors and prognosis in early breast cancer

In a study of the role of oestrogen-receptor analysis in early breast cancer the oestrogen-receptor content of the tumour was estimated in 286 patients undergoing mastectomy. These patients were followed for up to 39 months, and the recurrence of disease was noted in relation to the presence or absence of oestrogen receptor.Recurrence-rates were significantly higher in patients whose tumours did not contain receptors than in those whose tumours did. This same relationship was seen when women with and without axillary metastases were considered separately. The highest rates of recurrence were in women with axillary lymph-node involvement whose tumours lacked oestrogen receptors. Women without axillary-node involvement whose tumours lacked oestrogen receptors showed the same high rate of recurrence as all women with axillary-node involvement. The oestrogen-receptor content of a primary breast cancer appears to be an independent guide to early recurrence of the disease.

Squamous carcinoma of the breast

Two cases of primary squamous carcinoma of the breast are described. One of the tumours appeared to have an origin in an epidermoid cyst and had a pseudosarcomatous stroma. The other tumour arose from metaplastic ductal epithelium. A review of the literature is given.

Host cell deoxyribonucleic acid polymerase I and the support of T4 bacteriophage growth

Ultraviolet irradiation of Escherichia coli polA(-) cells reduces their capacity to support the growth of T4 phage. There is no additional loss of capacity observed in pol tsA(-)recA(-) double mutants at the nonpermissive temperature. The reversion frequency of a T4 rII mutant after ultraviolet irradiation is not changed by the absence of host deoxyribonucleic acid polymerase I.