Functionally unicuspid aortic valve in an adult: Case report and literature review

Aortic stenosis is one of the most prevalent cardiac valvular diseases throughout the world and has a significant impact on quality of life. While there are several etiologies, we will be discussing the case of a male in his mid-thirties of southeast Asian descent with a bicuspid aortic valve which was found to be functionally unicuspid and complicated by aortic dilation. Following a comprehensive review of literature, it appears this subset of aortic stenosis is not commonly encountered. In addition to presenting this fascinating case, we will review the epidemiology, classification and management of aortic stenosis. Furthermore, we will examine the latest evidence-based literature on bicuspid aortic valve and unicuspid aortic valve and discuss interventions and diagnostic tools that may improve clinical prognosis.

A Rare Case of Bartonella henselae Infective Endocarditis Causing an Embolic Cerebrovascular Accident

Bartonella is a facultative intracellular Gram-negative aerobic rod that is an important cause of culture-negative endocarditis that only accounts for 3% of all infective endocarditis (IE) cases. Throughout the literature, there have been very few documented cases of an embolic stroke caused by Bartonella henselae (B. henselae) IE. Following a comprehensive review of the literature, it appears that only a small number of articles have reported on the correlation between cerebrovascular accidents (CVAs) and Bartonella IE. Here, we present a case of a 42-year-old male with a cerebral embolic event as a complication of B. henselae IE.

An Interesting Case of Peripartum Cardiomyopathy With Biventricular Thrombi

Peripartum cardiomyopathy (PPCM) is a cause of heart failure that develops within five months postpartum. Biventricular thrombosis is a rare complication of PPCM with only a few cases reported in the literature. Here, we report a case of PPCM with biventricular thrombosis that was successfully treated with medical management.

Anti-Factor Xa Level Monitoring for Enoxaparin Prophylaxis and Treatment in High-Risk Patient Groups

Description Monitoring anti-factor Xa levels is a controversial topic in the inpatient setting due to resource utilization and unclear conditional guideline recommendations regarding this practice. Enoxaparin dosing in certain high-risk patient populations such as those with low body weight, obesity, renal insufficiency, and pregnancy has not been determined. The objective of this review was to assess the safety and efficacy of enoxaparin monitoring via anti-factor Xa levels in high-risk patient populations. The PubMed database was searched for articles related to low-molecular-weight heparin monitoring. Randomized controlled trials and meta-analyses that evaluated the safety and efficacy of enoxaparin prophylaxis and treatment in patients with extremes of weight, renal insufficiency, and pregnancy were selected. Fourteen studies representing four high-risk population patient groups were included. Patients with extremes of weight or who were pregnant were found to have subtherapeutic anti-factor Xa levels due to the weight-based dosing of enoxaparin. Those with renal insufficiency were found to be accumulating enoxaparin, indicating the need for a lower dose. Studies have shown that monitoring may be required in specific high-risk patient groups. Dose adjustments based on anti-factor Xa levels can prevent adverse events associated with enoxaparin. Further research involving larger patient populations would be necessary to determine the clinical efficacy of enoxaparin monitoring with anti-factor Xa levels.

Measurement and assessment of grief in a large international sample

BACKGROUND

In 2022, the International Classification of Diseases (ICD-11) and an update of the Diagnostic Statistical Manual of Mental Disorders (DSM 5 TR) were released for implementation worldwide and now include the new Prolonged Grief Disorder (PGD). The newest definition of PGD is based on robust clinical research from the Global North yet until now has not been tested for global applicability.

METHODS

The current study assesses the new PGD ICD-11 criteria in a large international sample of 1393 bereaved adults. The majority of the sample was included from the USΑ. Additionally, we conduct a sub-sample analysis to evaluate the psychometric properties, probable caseness of PGD, and differences in network structure across three regions of residency (USA, Greece-Cyprus, Turkey-Iran).

RESULTS

The psychometric validity and reliability of the 33-item International Prolonged Grief Disorder Scale (IPGDS) were confirmed across the whole sample and for each regional group. Using the strict diagnostic algorithm, the probable caseness for PGD for the whole sample was 3.6 %. Probable caseness was highest for the Greece-Cyprus group (6.9 %) followed by Turkey-Iran (3.2 %) and the USA (2.8 %). Finally, the network structure of the IPGDS standard items and cultural supplement items (total of 33 items) confirmed the strong connection between central items of PGD, and revealed unique network connections within the regional groups.

LIMITATIONS

Future research is encouraged to include larger sample sizes and a more systematic assessment of culture.

CONCLUSION

Overall, our findings confirm the global applicability of the new ICD-11 PGD disorder definition as evaluated through the newly developed IPGDS. This scale includes culturally sensitive grief symptoms that may improve clinical precision and decision-making.

COVID-19-Induced Complete Heart Block: Case Series and Literature Review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to the emergence of a wide range of complications, including those affecting the cardiovascular system. In this case series, we present four patients who developed complete atrioventricular block, a serious and potentially life-threatening heart rhythm disorder, during the course of their coronavirus disease 2019 (COVID-19) illness. The mechanisms by which SARS-CoV-2 may lead to arrhythmias are not fully understood but may involve direct infection and damage to heart tissue, as well as inflammation and cytokine storms. The extent and duration of complete heart block varied among these cases, highlighting the need for further research to understand the spectrum of disease and to improve mortality and morbidity in future waves of SARS-CoV-2 infections. We hope that this case series will draw attention to this serious complication of COVID-19 and inspire further research to improve management and outcomes for affected patients.

Rapidly Progressive Emphysematous Pancreatitis With Massive Hemorrhage and Multi-Organ Failure: A Severe Sequela of COVID-19

The COVID-19 global pandemic continues to wreak havoc on a number of affected patients and poses a significant burden on the healthcare system. Even though it has been over two years since the pandemic emerged, clinical presentations in affected patients continue to appall clinicians. Emphysematous pancreatitis is a rare, fatal complication of acute necrotizing pancreatitis presenting with a high mortality rate. This rare entity stems from superinfection of acute necrotizing pancreatitis with gram-negative bacteria, most commonly from Escherichia coli (E. coli), among others. Herein, we present a rare case of acute necrotizing pancreatitis complicated by emphysematous necrosis with hemorrhagic conversion and E. coli septicemia in a 60-year-old morbidly obese male patient without any underlying risk factors. He presented with respiratory failure in the setting of COVID-19 and was subsequently diagnosed with acute necrotizing pancreatitis complicated by emphysematous necrosis. To our knowledge, emphysematous pancreatitis in the setting of COVID-19 with no other attributable causes for pancreatitis was not previously reported in the literature. This article aims to report an unusual association between COVID-19 infection and acute emphysematous pancreatitis with evidence of hemorrhagic conversion. Furthermore, given the neoteric nature of this viral infection, we hope to promote sensitivity toward capturing additional clinical features associated with active COVID-19 infection, with the goal to keep clinicians abreast with its many possible sequelae.

An Unusual Case of Non-traumatic Chylothorax

Chylothorax refers to the presence of chyle in the paraaortic space. This entity most commonly occurs from injury to the thoracic duct, which carries chyle from the gastrointestinal tract to the bloodstream. Common etiologies around traumatic chylothorax include iatrogenic causes, such as surgical procedures near the thoracic duct and penetrating and blunt injuries to the chest. We present a case of a 49-year-old female who initially presented to the hospital with progressively worsening dyspnea leading to acute hypoxic respiratory failure requiring intubation and admission to the ICU. The patient's presentation was initially thought to be due to and managed as an infectious process with empyema and septic shock until a diagnosis of nontraumatic chylothorax was established. In this article, we report a complicated case of chylothorax, initially masquerading as an infectious pulmonary process. We hope to raise this entity high on the differential when clinicians are confronted with the task of managing patients with similar presentations, which will, in turn, prevent delayed diagnosis and the unnecessary use of antibiotics.

Approach to Cefepime-Induced Neurotoxicity in the Setting of Chronic Kidney Disease: A Case Report and Review of Literature

Cefepime-induced neurotoxicity is well-known, but an under-recognized event that can present with a myriad of neurological findings ranging from myoclonus to seizures to comatose state. It is more prevalent in patients with impaired renal clearance as it is mainly cleared by the kidneys. We present a case of a 52-year-old female who was managed in the intensive care unit with severe encephalopathy following empiric antibiotic therapy with cefepime. Although we encountered some unforeseen difficulties executing our initial plan of renal replacement therapy, our patient was successfully treated with fluids and intravenous diuresis with furosemide and was ultimately discharged home with full recovery.

A Rare Case of Purpura Fulminans in the Setting of Klebsiella pneumoniae Bacteremia

A 23-year-old man with circulatory shock associated with severe sepsis and congestive heart failure with an ejection fraction of 10% resulting in anasarca and multiorgan failure was admitted to our hospital's intensive care unit. Hours after admission, he developed a rash on his left inner thigh, which was later diagnosed as purpura fulminans (PF). Blood cultures were consistent with Klebsiella pneumoniae bacteremia, with community-acquired pneumonia being the possible source.

PF is a rare and difficult-to-diagnose entity characterized by dysregulated hemostasis that is often associated with poor prognosis and fatal outcomes. To our knowledge, there are limited reports in the literature on K. pneumoniae as a cause of PF. Given the rarity of this presentation, this case will serve as an opportunity to report and discuss the pathophysiology of this disease for the benefit of physicians.

COVID-19 and the Cardiovascular System: An Update

As COVID-19 continues to cause an increasing number of deaths worldwide, it is important that providers stay abreast with new research related to the pathophysiology of COVID-19 disease presentation states and clinical management. It is now well recognized that COVID-19 affects extrapulmonary organs, particularly the cardiovascular system. For example, cardiogenic shock has been increasingly observed in patients with COVID-19, owing to the various mechanisms involved and the affinity of the SARS-CoV-2 virus to cells comprising the cardiovascular system. In this review, we have briefly discussed the link between the cardiovascular system and COVID-19 infection, focusing on underlying mechanisms including but not limited to cytokine storm, direct virus-induced myocarditis, and ST-elevation myocardial infarction leading to cardiogenic shock. We have highlighted the cardiovascular risk factors associated with disease prognostication in COVID-19 patients. We have also briefly discussed vasopressors and inotropes used for treating shock and presented their mechanism of action, contraindications, and side effects in the hopes of providing a quick reference to help the provider optimize management of COVID-19 patients presenting with cardiovascular complications such as shock.

Marked Elevation of Carcinoembryonic Antigen Without an Identified Primary Gastrointestinal Tumor

Whether profound carcinoembryonic antigen (CEA) elevations, such as > 20 times the upper limit of normal, are of diagnostic use remain unknown. Herein, we present a case of a 55-year-old female with profound serum CEA elevation and multiple pelvic masses but with no evidence of a primary gastrointestinal tumor following upper endoscopy and colonoscopy. Subsequent immunostaining of resected pelvic masses confirmed adenocarcinoma of colorectal origin. This case report highlights the possible diagnostic role of profound CEA elevation, particularly in cases of unknown primary tumors.

Abstract P6-16-04: A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer

Background: Almost a quarter of older adults in the United States will identify themselves as Hispanic/Latino by 2060. Our group has previously developed and validated a self-administered geriatric assessment tool which can be used to identify functional, psychological, social and cognitive impairments among older patients with various types of cancer. Among English-speaking older adults, completing this tool using paper/pencil or a tablet takes a median of 15-21 minutes (min), with < 10% needing assistance to answer it (Hurria, JOP 2016). However, the utilization of this tool among Spanish-speaking older adults has not been tested. We assessed the feasibility of administering a translated and validated Spanish version of our geriatric assessment tool for older Hispanic women with breast cancer, and identified their preferred format (tablet or paper/pencil).

Methods: Spanish-speaking women aged ≥ 65 years with a diagnosis of breast cancer completed the geriatric assessment twice on the same day. Patients were randomized into 3 groups: paper/pencil twice; tablet and paper/pencil in random order; and tablet twice. We assessed the proportion of patients requiring assistance to complete the geriatric assessment, the time needed to complete it, and the proportion of patients who thought the geriatric assessment was difficult/very difficult.

Results: 140 older women with breast cancer completed the geriatric assessment twice and were evaluable. Mean age was 71.6 years (SD 5.8), 53% had ≤ 8th grade education, 43% were married, 45% were retired, 32% were homemakers, and 6% were employed. The participants came from 13 different Spanish-speaking countries, although 70% were born in Mexico. For 90%, Spanish was their primary language, and 75% spoke only in Spanish at home. Regarding computer skills, 64% of the patients said they had none. 39% (n = 54) were unable to complete the geriatric assessment on their own; mean time to complete the geriatric assessment was 29 min (range 8-90); and 28% (n = 39) thought the geriatric assessment was difficult/very difficult. The most common reasons for needing assistance were difficulty understanding questions (39%) and visual problems (31%). Patients with ≤ 8th grade education took longer to complete the geriatric assessment (mean 37.2 vs 29.4 min, p < 0.01), and more often needed help completing the assessment (51% vs 19%, p < 0.01) than those with ≥9th grade education. 53% of the participants preferred using a tablet to answer the geriatric assessment, while 47% preferred paper/pencil.

Conclusions: A substantial proportion of Spanish-speaking older women with breast cancer required assistance to complete our self-administered geriatric assessment tool. This may be a consequence of the low educational level we found among this patient population. Tailoring assessments for diverse populations with particular attention to educational level is needed in multicultural settings.

Citation Format: Soto-Perez-de-Celis E, Vazquez J, Kim H, Sun C-L, Somlo G, Yuan Y, Waisman JR, Mortimer JE, Kruper L, Taylor L, Patel NH, Moreno J, Charles K, Roberts E, Uranga C, Levi A, Katheria V, Paredero-Perez I, Mitani D, Hurria A. A self-administered geriatric assessment tool for Spanish-speaking older women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-04.

Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: systematic review and mixed treatment comparison meta-analysis

AIMS

To review the evidence on interventions for reversing metabolic syndrome or preventing development of type 2 diabetes and cardiovascular disease in people with metabolic syndrome.

METHODS

A systematic review and Bayesian mixed treatment comparison meta-analysis was conducted. Relevant electronic bibliographic databases were searched up to January 2010. Included studies were randomized controlled trials with a follow-up of ≥24 weeks and outcomes comparing incidence of diabetes and/or cardiovascular disease, or reversal of metabolic syndrome.

RESULTS

A total of 16 studies met the inclusion criteria. Thirteen studies with outcome data for reversal of metabolic syndrome, involving 3907 participants, were included in the meta-analysis. Insufficient trials reported cardiovascular events/mortality, or incidence of type 2 diabetes, to conduct a meta-analysis for these outcomes. Interventions, alone or in combination, included lifestyle (diet and/or exercise) and pharmacological therapy. Using random-effect models, both lifestyle (odds ratio, OR 3.81; 95% confidence interval, CI 2.47-5.88) and pharmacological interventions (OR 1.59; 95% CI 1.04-2.45) were statistically superior compared with control for reversing metabolic syndrome. Using mixed treatment comparison methods, the probability that lifestyle interventions were the most clinically effective was 87%.

CONCLUSIONS

Evidence suggests that both lifestyle and pharmacological interventions can reverse metabolic syndrome. However, there is a lack of data on whether these benefits are sustained and translate into longer term prevention of diabetes and/or cardiovascular disease.

Steroid-Induced Iatrogenic Disease After Treating for Pseudothrombocytopenia

Pseudothrombocytopenia, a spontaneous in vitro occurrence after the addition of anticoagulant to blood, causes clumping of platelets resulting in a spurious observation of low platelet counts (<10 000/μL) without any associated hemorrhagic manifestations. We describe a 46-year-old male patient who was diagnosed with immune thrombocytopenic purpura (ITP) based on a reported platelet count of 22 000/μL. He was prescribed high-dose glucocorticoid therapy, up to 60 mg of prednisolone daily for over a year. After repeated hospital admissions, he came under our care as an emergency admission for nonketotic hyperosmolar hyperglycemia. He was diabetic, osteopenic, and had been treated for tuberculosis, all likely consequences of prolonged glucocorticoid therapy. In the presence of persistent platelet counts below 10 000/μL, and without associated clinical hematological manifestations of ITP, a smear of citrated blood was examined and a platelet count of 215 000/μL was observed. This case highlights the possible consequences of misdiagnosis of pseudothrombocytopenia. Failure to recognize this phenomenon may lead to debilitating iatrogenic disease.

Soil inactivation of DNA viruses in septic seepage

AIMS

To generate field-relevant inactivation data for incorporation into models to predict the likelihood of viral contamination of surface waters by septic seepage.

METHODS AND RESULTS

Inactivation rates were determined for PRD1 bacteriophage and Adenovirus 2 in two catchment soils under a range of temperature, moisture and biotic status regimes. Inactivation rates presented for both viruses were significantly different at different temperatures and in different soil types (alpha = 0.05). Soil moisture generally did not significantly affect virus inactivation rate. Biotic status significantly affected inactivation rates of PRD1 in the loam soil but not the clay-loam soil. Adenovirus 2 was inactivated more rapidly in the loam soil than PRD1 bacteriophage.

CONCLUSIONS

Virus inactivation rates incorporated into models should be appropriate for the climate/catchment in question with particular regard to soil type and temperature. Given that PRD1 is similar in size to adenoviruses, yet more conservative with regard to inactivation in soil, it may be a useful surrogate in studies of Adenovirus fate and transport.

SIGNIFICANCE AND IMPACT OF THE STUDY

A better understanding of the factors that govern virus fate and transport in catchments would facilitate the design of barrier measures to prevent viral contamination of surface waters by septic seepage.

Disaggregation and valuation of collective dose and global circulation dose

This study is an extension of earlier work (Jones et al 2004 J. Radiol. Prot. 24 13-27) using an adaptation of the PC-CREAM computer model (Mayall et al 1997 NRPB-SR296 (EUR 17791 EN) (Chilton: NRPB)) applied to future discharge scenarios for the nuclear fuel reprocessing plant at Sellafield, Cumbria, UK. This work showed that, of the total 3700 person-Sv collective dose delivered to the world population over 500 years integration from a particular scenario (SF3), 95% is at levels of individual dose below 0.015 microSv y(-1). The collective dose delivered at individual dose rates below 0.015 microSv y(-1) reflects the contribution from globally circulating radionuclides, namely (3)H, (14)C, (85)Kr and (129)I. The methodology used in the earlier work could not break down the dose from globally circulating radionuclides into bands of individual dose; the principal aim of this study is to achieve such a breakdown. The results confirm that the global circulation dose is received in the very lowest bands i.e. all below 0.015 microSv y(-1) for atmospheric discharges, and all below 0.0015 microSv y(-1) for discharges to the sea in the SF3 scenario. If account is taken of the argument that the monetary value of the detriment associated with collective dose should reduce with decreasing levels of individual dose or risk (Jackson et al 2004 J. Radiol. Prot. 24 41-59; NRPB 1993 Doc. NRPB 4 (2) 75-80) then it can be shown that the value of the detriment associated with discharges in the SF3 scenario would be substantially reduced compared with that derived from current conventional assumptions.

Buffer distances for on-site sewage systems in Sydney's drinking water catchments

Pathogens and nutrients released from on-site sewage systems represent a risk to surface and ground water quality, particularly where there are sensitive receiving waters such as in drinking water catchments. Buffer zones between on-site systems and waterways are one barrier used to protect water quality. The increased time and distance they provide increases the opportunities for the effluent purification functions of the soil to occur. A risk management model is proposed to assess the efficacy of the buffer zones in Sydney's drinking water catchments. The model is the basis for the development of performance based setback distances for on-site systems from waterways, and incorporates stochastic analysis of pathogen and nutrient transport in the environment and consideration of the effluent quality variability from on-site systems. Catchment-scale integration of contaminant transport is employed to facilitate a risk assessment of on-site systems. The risk management model also allows for the impact of on-site system management and maintenance on catchment water quality to be assessed through scenario building and feedback mechanisms.

MEAD (part II)-Predictions of radioactivity concentrations in the Irish Sea

The predictions from MEAD, a model that simulates the transport of radionuclides in the marine environment, are presented for the Irish Sea. MEAD predictions for (137)Cs and Pu(alpha) are presented following discharges from BNFL Sellafield and the predictions compared to measured data from near the discharge location and further a field in the Irish Sea. The model performs well in most circumstances given the uncertainties involved in both modelling and data collection although some inconsistencies in the predictions are found. MEAD is also compared to other models of radionuclide transport in the Irish Sea.

Centralised versus decentralised sewage systems: a comparison of pathogen and nutrient loads released into Sydney's drinking water catchments

Data collected from centralised and decentralised sewage treatment plants throughout Sydney's drinking water catchments was used to calculate the relative catchment loads of Cryptosporidium, enteric viruses, nitrogen and phosphorus for an initial screening assessment. Loads were assessed at median and 90 percentile values for expected and worst-cases scenarios. The expected scenario in the Sydney drinking water catchments is that decentralised systems (servicing 32,800 people) provide similar total loads to centralised systems (serving 70% of the catchment population) for total phosphorus (37,090 kg x y(-1)), Cryptosporidium (10(11) oocysts x y(-1)) and enteric viruses (9.1 x 10(13) y(-1)), but higher loads of total nitrogen (237,610 vs. 136,740 kg x y(-1)). Decentralised systems, however, were predicted to have higher loads in the worst-case scenario with 620,620 kg x y(-1) TN, 82,040 kg x y(-1) TP, 7.3 x 10(13) Cryptosporidium oocysts x y(-1) and 9 x 10(15) enteric viruses per year. Greater load variability was experienced with decentralised systems, which presumably reflects less reliability in their current operation and maintenance. Overall, catchment water quality is therefore not only affected by sewage disposal methods, but also failure issues. Decentralised system disposal to land may afford a degree of mitigation that can be enhanced, if the degree of failure is reduced.

[Family planning among teenage mothers in a Cameroonian centre]

This study was carried out in Yaounde (Cameroon) in 1995 to determine the knowledge, attitude and behaviour of teenage mothers towards family planning. The study was based on a questionnaire administered at household level drawn from previously determined clusters. It was accomplished by recruiting 462 teenage mothers with ages ranging from 14 to 19 years and who had 1 to 3 children. On the whole, 93.9% had heard of family planning, 72.5% had heard of family planning centres, but only 43% had been to one of these centres at least once. With regards to contraceptive prevalence, 62.1% affirmed the use of a contraceptive method at the time of the study with periodic abstinence being the most widely used (35.9%). Besides the common methods, some teenage mothers made use of herbal concoctions and vaginal douching, sometimes with permanganate or the taking of tablets. Nineteen per cent of respondents had had between one and four episodes of induced abortion. According to these teenagers, the ideal average age for first delivery is 19.7 +/- 2.5 years, whereas that of nubility is 22.8 +/- 3.3 years, a difference of 3 years. This suggests that on the whole, teenage mothers believe that first delivery must precede marriage.

Homogeneous preparations of 3'-phosphoglycolate-terminated oligodeoxynucleotides from bleomycin-treated DNA as verified by electrospray ionization Fourier transform ion cyclotron resonance mass spectrometry

Single- and double-strand breaks bearing 3'-phosphoglycolate termini are among the most frequent lesions formed in DNA by ionizing radiation and other oxidative mutagens. In order to obtain homogeneous preparations of defined 3'-phosphoglycolate substrates for repair studies, 5'-(32)P-end-labeled partial duplex DNAs were treated with bleomycin, and individual cleavage products were isolated from polyacrylamide gels. The fragments were then treated with alkaline phosphatase and further purified by reverse-phase HPLC. Electrospray ionization Fourier transform ion cyclotron resonance (ESI-FTICR) mass spectrometry of the purified oligomers produced molecular ions of the expected masses, with no detectable contaminants. Gas-phase sequencing by tandem mass spectrometry of these single species yielded the expected sequence ions and confirmed the presence of phosphoglycolate on the 3'-terminal fragments only. The fragments could be relabeled with polynucleotide kinase to yield highly purified, high-specific-activity substrates for repair studies.

Meckel's diverticulum

Although Meckel's diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. It may remain completely asymptomatic, or it may mimic such disorders as Crohn's disease, appendicitis and peptic ulcer disease. Ectopic tissue, found in approximately 50 percent of cases, consists of gastric tissue in 60 to 85 percent of cases and pancreatic tissue in 5 to 16 percent. The diagnosis of Meckel's diverticulum should be considered in patients with unexplained abdominal pain, nausea and vomiting, or intestinal bleeding. Major complications include bleeding, obstruction, intussusception, diverticulitis and perforation. The most useful method of diagnosis is with a technetium-99m pertechnetate scan, which is dependent on uptake of the isotope in heterotopic tissue. Management is by surgical resection.

Storage and microencapsulation of islets for transplantation

Microencapsulation is an effective means of immunoisolation for pancreatic islet transplants. However, the process of isolating, purifying, encapsulating, and transplanting islets in a single day is labor intensive and difficult for routine use. There is an apparent need for reliable methods of islet storage, and cryopreservation has emerged as an attractive system of islet banking. While studies have shown that cryopreserved islets are viable when tested unencapsulated after thawing, it is not clear if the combination of freezing and encapsulation would affect islet function. The purpose of the present study was to determine the in vitro function of cryopreserved islets following thawing and microencapsulation. Islets were isolated from the pancreata of Sprague-Dawley rats and cryopreserved under liquid nitrogen for either 1 week or 1 month, following an overnight culture at 37 degrees C. Upon thawing, the islets were tested either unencapsulated or after encapsulation in polylysine-alginate membrane. In all experiments islets were preperifused for 1 h at 37 degrees C with a modified Krebs-Ringer bicarbonate buffer containing 3.3 mM (60 mg/dl) glucose and maintained at pH 7.4 by continuous gassing with 95% air/5% CO2. Following basal effluent sample collection on ice, the glucose concentration was raised to 16.7 mM (300 mg/dl). It was found that, within 10 min of high glucose stimulation, an average of twofold increase in insulin secretion (p < 0.01) was obtained in islets within or without microcapsules. We conclude that islets cryopreserved for 1 month prior to thawing and microencapsulation retained functional viability as determined in in vitro experiments.

Action of bleomycin on structural mimics of intermediates in DNA double-strand cleavage

Bleomycin-induced cleavage was examined in several nicked, gapped, or intact duplex DNA substrates, including a structure designed to mimic a proposed singly nicked intermediate in double-strand cleavage. This nicked structure appeared to correctly target the second cleavage event in the complementary strand, resulting in a blunt-ended double-strand break, similar to that induced directly by bleomycin alone in an intact duplex of the same sequence. A one-base-gapped structure was markedly less efficient in correctly targeting bleomycin attack in the complementary strand. The results are consistent with a model of bleomycin-induced double-strand cleavage in which the nick formed by the initial bleomycin attack serves to target secondary attack to a specific position in the complementary strand, resulting in a double-strand break with a defined geometry.

A prospective study of serum pancreatic elastase-1 in the diagnosis and assessment of acute pancreatitis

BACKGROUND

Serum amylase gives a poor estimate of both the true incidence and the severity of acute pancreatitis (AP).

METHODS

We evaluated serum pancreatic elastase-1 (PE-1) prospectively in 567 patients in whom AP was suspected. In established AP, severity was assessed using the Glasgow Criteria, and C-reactive protein, amylase, and serum PE-1 were evaluated over 5 days.

RESULTS

The sensitivity, specificity, and diagnostic efficiency of serum PE-1 were 0.66, 0.85, and 0.84, respectively. The diagnostic accuracy of serum PE-1 was 0.80, and that of amylase 0.97. Serum PE-1 did not correlate with disease severity or the development of complications, but it fell more slowly than the serum amylase in the week after admission.

CONCLUSIONS

The serum PE-1 level correlated closely with the serum amylase but conferred no benefit as a diagnostic test, nor did it provide further prognostic information.

Monofunctional adenine N-3 adducts of melphalan: occurrence at a mutational hotspot sequence and resistance to removal by AlkA protein

Previous work showed that a CTAAA sequence in the supF gene of the shuttle plasmid pZ189 was a hotspot for mutagenesis by the aromatic nitrogen mustards melphalan and chlorambucil, and indirect evidence suggested adenine N-3 adducts as premutagenic lesions. In order to characterize the adducts formed at this sequence more directly, a substrate was prepared in which the three adjacent adenines in the CTAAA sequence were 3H-labeled. Following treatment of this substrate with [14C]melphalan, thermolabile adducts were depurinated and analyzed by HPLC. Only a single peak bearing both 3H and 14C label was detected and it coeluted with the single major adduct formed by the reaction of melphalan with free adenine base. Various spectrometric analyses of this species were all consistent with its identification as a monofunctional adenine N-3 adduct of melphalan. There was no evidence for any bifunctional adducts involving the labeled adenines. There was little if any release of the adenine N-3 adduct of melphalan by Escherichia coli AlkA protein, under conditions where 3-methyladenine was quantitatively released. The results support the proposal that monofunctional adenine N-3 adducts are intermediates in the generation of A.T-->T.A and A.T-->C.G transversions by aromatic nitrogen mustards.

A patient with unique bilateral ovarian metastases 11 years after the treatment of breast cancer

We report a patient in whom 11 years after the treatment of a breast tumour, bilateral ovarian metastases were disclosed. Surgical exploration confirmed unique ovarian metastases within a 'clean' abdomen and pelvis. The particularities of this case compared with the literature are the rather long interval of 11 years and the fact that no other metastases were present. The literature indeed reveals that most of the patient with ovarian metastases are premenopausal, have bilateral involvement; the ovarian metastases occur within a few years and are frequently accompanied by other metastases.

Reported changes in the sexual behavior of men at risk for AIDS, San Francisco, 1982-84--the AIDS Behavioral Research Project

We surveyed 454 men in November 1983 and in May 1984 regarding their sexual practices during the month before the survey. In the 1983 survey, we also asked for reports about sexual behavior during the same month 1 year prior to the survey. The sample consisted of men recruited as they left bath-houses and bars, men who had not used bars or baths for meeting sexual partners for 2 months prior to the November 1983 survey, and men in committed primary relationships with another man. We found substantial changes in reported sexual behavior with persons other than a primary partner. The average number of male partners declined from 6.3 in November 1982 to 3.9 in May 1984. Receptive anal intercourse without condom declined from 1.9 to 0.7, oral-anal contact declined from 1.1 to 0.3, and swallowing semen declined from 2.8 to 0.7 in terms of the number of times that the respondent engaged in the act in the last month. These same changes did not occur in relation to sex with a primary partner. Only one variable, namely, increased length of time since the first homosexual experience, distinguished persons maintaining few sexual partners from those increasing the number of sexual partners from November 1983 to May 1984. Four variables distinguished those retaining high numbers of sexual partners from those lowering the number of sexual partners, namely, ability to remember a visual image of AIDS deterioration, age, relationship status, and length of time since first homosexual experience.