Transjugular intrahepatic portosystemic shunt creation via isolated persistent left superior vena cava: a case series

BACKGROUND

Isolated persistent left superior vena cava (PLSVC) is a rare vascular anatomic variant, which can be an incidental finding at the time of an endovascular procedure.

CASE PRESENTATION

This report describes the technical success, adverse events, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation via isolated PLSVC. Three adult patients with cirrhosis and isolated PLSVC underwent TIPS placement successfully with one major adverse event. Two patients required TIPS revision within 90 days. There were no deaths within 90 days.

CONCLUSIONS

TIPS creation via isolated PLSVC is feasible using standard techniques with a left jugular vein approach. Caution is warranted during the procedure to assess for any aberrant drainage pattern to the left atrium and to prepare for potentially challenging instrument navigation through the coronary sinus.

Thoracic Duct Embolization-Value Analysis Using a Time-Driven Activity-Based Costing Approach: A Single Institution Experience

PURPOSE

To quantify cost drivers for thoracic duct embolization based on time-driven activity-based costing methods.

MATERIALS AND METHODS

This was an Institutional Review Board-approved (HUM00141114) and Health Insurance Portability and Accountability Act-compliant study performed at a quaternary care institution over a 14-month period. After process maps for thoracic duct embolization were prepared, staff practical capacity rates and consumable equipment costs were analyzed via a time-driven activity-based costing methodology. Sensitivity analyses were performed to identify primary cost drivers.

RESULTS

Mean procedure duration was 4.29 hours (range: 2.15-7.16 hours). Base case cost, per case, for thoracic duct embolization was $7466.67. Multivariate sensitivity analyses performed with all minimum and maximum values for cost input variables yielded a cost range of $1001.95 (minimum) to $89,503.50 (maximum). Using local salary information and negotiated prices for materials as cost parameters, the true cost per case of thoracic duct embolization at the study institution was $8038.94. Univariate analysis demonstrated that the primary driver of staffing costs was the length of time the attending anesthesiologist was present. The predominant modifiable cost drivers included cyanoacrylate glue volume used (minimum $4467; maximum $12,467), cost of glue utilized (minimum $5217; maximum $10,467), and cost of coils utilized (minimum $7377; maximum $10,917). Univariate analysis predicted that the use of Histoacryl glue in place of TRUFILL cyanoacrylate glue resulted in a cost savings of $2947.50 per case.

CONCLUSIONS

The base cost per case for thoracic duct embolization was $7466.67. Costs, namely anesthesia staffing costs, cyanoacrylate glue, and coils were large, potentially modifiable drivers of overall cost for thoracic duct embolization.

Virtual brain tumor histopathology and immunohistochemistry with stimulated raman scattering microscopy

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Background: Stimulated Raman scattering (SRS) microscopy is a label-free optical technique which uses the chemical composition of fresh tissue to generate image contrast. Prior work has demonstrated exceptional correlation between SRS images and H&E microscopy for detecting brain tumor infiltration ex vivo. However, SRS has not previously been suitable for a clinical environment. Further, SRS has utilized structural, rather than chemical, diagnostic features. We present the first clinical validation of SRS, as well as our work towards mutation-targeted SRS imaging. Methods: Implementation of SRS with a fiber laser source allowed sufficient stability for clinical deployment. Unprocessed specimens from 200 neurosurgical cases were imaged at the CH2 and CH3 vibrational modes, then processed to mimic the appearance of H&E staining. 30 cases were trialed in a simulated intraoperative consultation to assess concordance between SRS and cryosection microscopy. A multi-layer perceptron (MLP) model was then used to predict brain tumor diagnosis based on quantified image attributes. To explore the potential for chemically specific SRS, isogenic lines of normal human astrocyte were prepared, differing by the presence or absence of the R132H mutation in the isocitrate dehydrogenase 1 (IDH1) gene. IDH1 R132H cells accumulate high concentrations of the oncometabolite 2-hydroxyglutarate and display predictably altered metabolism. 200 Raman spectra were collected from 50 wild type (WT) and 50 R132H cells with the aim of detecting these changes. Each cell line was then submitted for targeted metabolomic analysis. Results: Excellent concordance was observed between SRS and frozen section histology ( κ >0.89). The MLP diagnosed brain tumor subtype with 90% accuracy. A robust spectral difference was observed between wild type and R132H cells, which showed concordance with metabolomic data. Conclusions: The diagnostic capability, ease of use and speed of SRS make it well-suited for integration into the operative workflow. Further, because SRS amplifies the Raman signal with no resonant background, the spectral differences observed may allow rapid differentiation of IDH1 WT and R132H cells with SRS.

Simultaneous Bilateral Vertebral Artery 3D Rotational Angiography. Technical Report of Two Cases

SUMMARY

We describe the first reported use of simultaneous bilateral vertebral artery rotational angiography to visualize an aneurysm. Images acquired from 3D rotational angiography with a single vertebral injection provided insufficient anatomic detail in two cases with vertebrobasilar junction aneurysms associated with fenestration. Therefore, simultaneous bilateral vertebral artery 3D rotational runs were performed. Anatomic detail was superior with the simultaneous injection and this allowed for the appropriate plan of care to be instituted. In the rare cases of vertebrobasilar junction aneurysm associated with fenestration, simultaneous bilateral vertebral artery 3D rotational angiography may provide the most useful anatomic detail when evaluating a patient for possible endovascular intervention.

Transcranial Doppler identification of changing autoregulatory thresholds after autoregulatory impairment

OBJECTIVE

Transcranial Doppler (TCD) flow velocity (FV) assessment may provide a useful index of autoregulatory impairment after severe head injury. It may define a therapeutic end point against which cerebral perfusion pressure (CPP) can be titrated. This study examines the relationship between cerebral blood flow (CBF) and TCD FV indices in a laboratory model before and after autoregulatory impairment.

METHODS

CPP, CBF, and middle cerebral artery TCD FV were measured continuously in nine anesthetized and ventilated sheep. CPP was decreased by hemorrhagic hypotension. The process was repeated after impairment of autoregulation by cisternal infusion, which maintained CPP at 0 mm Hg for 15 minutes. Points of significant change (i.e., breakpoints) from baseline values for each of the measured flow parameters were identified by using a ratio of variance technique.

RESULTS

Before any significant change in CBF or systolic TCD, diastolic TCD FV decreased (mean breakpoint, 69 mm Hg; range, 56-78 mm Hg) as CPP was reduced. This divergence of diastolic and systolic TCD FV, which occurred before autoregulatory failure, was associated with an increasing TCD pulsatility index (mean breakpoint, 63 mm Hg; range, 53-70 mm Hg). At diastolic TCD FV congruent with 10 cm/s, systolic TCD FV (mean breakpoint, 48 mm Hg; range, 46-53 mm Hg) and CBF (mean breakpoint, 49 mm Hg; range, 47-51 mm Hg) decreased rapidly, indicating autoregulatory failure. After autoregulatory impairment, the breakpoints for all four indices shifted to higher CPP values (mean, 16 mm Hg).

CONCLUSION

TCD FV assessment identified two CPP thresholds of autoregulatory loss. Before autoregulatory failure, an earlier phase of autoregulatory disturbance may be detected by divergent systolic and diastolic TCD FVs. It is important to note that this phase may be detected before CBF decreases. These TCD FV breakpoints depend on the state of autoregulatory impairment and may provide potential targets for CPP-directed therapy.

Mannitol for resuscitation in acute head injury: effects on cerebral perfusion and osmolality

OBJECTIVE

To review the use of mannitol during initial resuscitation following traumatic brain injury and to determine the effects of mannitol on subsequent management following resuscitation and commencement of neuromonitoring.

METHODS

A retrospective audit of patients presenting to a tertiary hospital with severe head injury (Glasgow coma score < or = 8). Patients were divided into two groups according to whether they received mannitol during initial resuscitation. Measurements included initial plasma osmolality, cerebral perfusion pressure (CPP), intracranial pressure (ICP) and jugular venous saturation (SjO2).

RESULTS

Forty patients were identified: 19 received mannitol prior to admission to the intensive care unit. Of these, only 2 patients fulfilled acceptable neurological indications for mannitol. The mannitol patients received a mean dose of 237 mL of 20% mannitol (47.4 g) and had significantly higher initial osmolalities than the patients who did not receive mannitol (293 vs 279 mosmol/L, p < 0.05). No significant difference in initial CPP, ICP, or SjO2 was identified. The mannitol patients were further subdivided into two 12-month periods (1994 and 1995). A dose related, significant difference in initial osmolalities was identified (140 vs 344 mL and 284 vs 304 mosmol/L respectively, p < 0.05). The latter group (n = 9) had significantly lower initial CPPs (72 vs 59 mmHg) and higher ICPs (14 vs 18 mmHg). No difference in 6 month Glasgow outcome scores between groups was demonstrated.

CONCLUSIONS

The empirical overuse of mannitol is common. Mannitol did not exert any beneficial effect on CPP, ICP or SjO2 in the initial phases of management. Larger doses (i.e. > 20 g) are associated with increased osmolality which may reduce CPP.

Cerebrovascular pressure transmission analysis as a guide to the pathophysiology of raised intracranial pressure

1. Raised intracranial pressure (ICP) is a major factor associated with morbidity and mortality in patients with severe head injury. Identifying the mechanisms responsible for raised ICP may be difficult and, as a result, treatment prescribed may be non-specific and often ineffective. 2. Research aimed at obtaining more information from measurement of ICP was initially focused on measurements of compliance. This was achieved by introducing fluid volume into the craniospinal compartment and measuring the response. Although shown to be clinically useful, associated technical problems have precluded the routine use of these measurements. 3. Cerebrovascular pressure transmission (CVPT) analysis has been suggested as an alternative method of deriving more information from the ICP wave-form. Pressure transmission across the cerebrovascular bed is assessed by a systems analysis approach whereby blood pressure and ICP wave-form pairs are resolved by fast Fourier transform analysis into component harmonic frequencies, each with a specific amplitude and phase. These are expressed as a ratio or 'transfer function' for each harmonic peak. 4. Laboratory models have identified specific CVPT patterns associated with various causes of raised ICP. These studies have been extended to clinical practice and have been used to define patterns of CVPT in head-injured patients, which may be used to identify mechanisms responsible for raised ICP, thus assisting in directing treatment strategy. Clinical usefulness of this technique in patient management is currently under investigation.

The effect of bleaching agent on composite/enamel bonding

This in vitro study evaluates the effect of an in-office light-activated hydrogen peroxide bleaching agent on the shear bond strength of composite resin to etched enamel. Specimens were divided into 4 groups. Group 1 specimens were not bleached and served as the control; Group 2 consisted of specimens bonded immediately after bleaching; Groups 3 and 4 of specimens bonded 1 and 2 weeks respectively after bleaching. The mean shear bond strengths (MPa) of Groups 2 (14.2 +/- 4.9), 3(19.2 +/- 3.2) and 4 (23.1 +/- 3.7) were lower than the value obtained in Group 1 (25.1 +/- 3.7). Groups 2 and 3 had significantly lower shear bond strengths than the unbleached Group 1 (25.1 +/- 3.7). It is suggested that bonding procedures be postponed for two weeks after any bleaching procedure had been done.

Juvenile glaucoma linked to the GLC1A gene on chromosome 1q in a Panamanian family

PURPOSE

To characterize clinically and genetically autosomal dominant juvenile-onset primary open-angle glaucoma in a Panamanian family.

METHODS

Twenty members of a six-generation family underwent ophthalmologic examination and genetic screening with markers near the GLC1A gene on chromosome 1q.

RESULTS

Linkage analysis disclosed evidence linking primary open-angle glaucoma in this family to the GLC1A gene on chromosome 1q, with a maximum lod score of 3.75 for marker D1S431 at an estimated recombination fraction of 0.00.

CONCLUSIONS

This is the first report of a Panamanian family in which primary open-angle glaucoma is linked to the GLC1A gene on chromosome 1q.

A head impact model of early axonal injury in the sheep

Axonal injury (AI), one of the principal determinants of clinical outcome after head injury, may evolve over several hours after injury, raising the future possibility of therapeutic intervention during this period. A new head impact model of AI in sheep was developed to examine pathological and physiological changes in the brain resulting from a graded traumatic insult. In this preliminary study 10 anesthetized and ventilated Merino ewes were used. Head injury was produced by impact from a humane stunner to the temporal region of an unrestrained head. Eight sheep were studied for 1, 2, 4, or 6 h after impact. Two sham animals (no impact, 6 h survival) were also examined. Arterial blood pressure, intracranial pressure, and cerebral blood flow were monitored continuously. A physiological index of injury severity was calculated by weighting the percentage shift from preinjury values for each monitored parameter over the first hour after injury. Immunostaining with amyloid precursor protein (APP) was used as a marker of axonal damage and the distribution of APP positive axons was recorded according to a sector scoring method (APPS). Widespread AI was identified in 7 of the 8 impacted animals, around cerebral contusions and in hemispheric white matter, central gray matter, brain stem, and cerebellum, and was detected as early as 1 h after injury. The degree of axonal injury (APPS) correlated well with an index of physiological response to injury (r = 0.83, p = 0.005).

Cerebral oxygenation monitoring by near-infrared spectroscopy is not clinically useful in patients with severe closed-head injury: a comparison with jugular venous bulb oximetry

OBJECTIVE

To compare continuous jugular venous bulb oximetry and cerebral near-infrared spectroscopy in patients with severe closed head injury.

DESIGN

A prospective observational study.

SETTING

Intensive care unit of a major teaching hospital.

PATIENTS

Adults (n = 10) with severe closed-head injury (Glasgow Coma Scale score of < or = 8).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Jugular venous bulb oximetry, cerebral near-infrared spectroscopy, and cerebral perfusion pressure were measured continuously. A total of 3,691 paired measurements of near-infrared spectroscopy and jugular venous bulb oximetry were analyzed. Poor correlation (r2 = .04) between paired measurements and wide limits of agreement (-13% to +21%) were demonstrated. The mean difference between measurements was +/- 4% and the standard deviation of the mean difference was +/- 8.69%. The data were subsequently grouped according to three clinically significant subgroups of jugular venous bulb oxygen saturation reflecting low ( < 55%), normal (55% to 75%) and high ( > 75%) saturation values. Poor correlation and wide limits of agreement between the two methods of measurement were observed in all groups. Values recorded by near-infrared spectroscopy did not significantly change between the groups, and 14 clinically significant episodes of jugular venous bulb desaturation were not detected by near-infrared spectroscopy.

CONCLUSIONS

Tissue oxygen saturation determined by near-infrared spectroscopy does not reflect significant changes in cerebral oxygenation detected by the global measurement of jugular venous bulb oximetry. This finding may be explained by inadequate signal detection and inaccuracies in the algorithm used to filter out extracranial components. Until these technical difficulties are addressed, near-infrared spectroscopy, as measured by the machine assessed in this study, cannot be routinely recommended for assessment of cerebral oxygenation in patients with acute head injury.

Juvenile glaucoma linked to GLCIA in a Panamanian family

PURPOSE

To carry out clinical and genetic characterization of juvenile-onset primary open-angle glaucoma (POAG) inherited as an autosomal dominant trait in a Panamanian family.

METHODS

Twenty-two members of a six-generation Panamanian family underwent an ophthalmologic evaluation. Blood samples were collected from 20 of these individuals for preparation of DNA for use in screening of microsatellite repeat genetic markers via polymerase chain reaction.

RESULTS

Eleven living family members covering 4 generations were diagnosed as affected with open-angle glaucoma of primarily juvenile onset. Four of 6 other at-risk individuals examined and enrolled were characterized as unaffected and two as indeterminate. Two additional individuals were not included in this study because they were too young to characterize or to provide a blood sample. Three spouses of affected family members were also examined and found not to have glaucoma. Of clinical importance was the finding of markedly elevated intraocular pressure (IOP) in 2 affected brothers, both of whom were advised to have urgent filtration surgery; the finding of elevated IOP in the only seeing eye of the mother of these brothers, causing us to advise her to pursue more aggressive treatment; and the finding of early signs of glaucoma in a previously undiagnosed 9-year-old family member. Linkage analysis using selected microsatellite repeat markers in the 1q21-q31 region revealed strong evidence for linkage to the GLC1A gene with a maximum lod score of 3.75 for marker D1S431 at a recombination fraction of 0.00.

CONCLUSIONS

The most likely interpretation of our data is that a mutation in the GLC1A gene is responsible for juvenile-onset POAG in this Panamanian family, thus expanding the countries of origin where this gene has been found to exist. The numbers of families with GLC1A glaucoma now reported from only a few centers worldwide raise questions about whether this disease may be more common than once thought. Evaluation of treatment histories and clinical outcomes in members of this and other previously reported families indicates that ophthalmologists need to understand the necessity for urgent filtration surgery in most cases of GLC1A glaucoma if vision is to be preserved.

Detection of cerebral venous desaturation by continuous jugular bulb oximetry following acute neurotrauma

A prospective observational study was performed to assess the reliability of fibreoptic oximetric catheters and to identify the incidence and causes of jugular bulb oxygen desaturation in patients with acute closed head injury. There were twenty-five patients (30 +/- 16 years) with GCS < or = 8 in this study. Jugular bulb oximetry, mean arterial pressure, intracranial pressure, end-tidal CO2 and pulse oximetry were monitored continuously. Catheter calibration against a laboratory oximeter was performed post insertion and thereafter eight-hourly. Cerebral venous desaturation was defined as a jugular bulb oxygen saturation < 55% of > 10 minutes duration. There was a poor correlation for the first in vivo calibration (r2 = 0.602, P < 0.001, n = 25). Thereafter a close correlation between jugular bulb catheter and oximetry values was demonstrated (r2 = 0.868, P < 0.001, n = 205). Forty-two episodes of jugular bulb oxygen desaturation of 88 minutes mean duration (range 10 to 555) were observed. 83% occurred within 48 hours following injury. Hypocapnia was associated in 45% of episodes; hypoperfusion in 22%; raised ICP in 9% and a combination of the above in 24%. Validation with a laboratory oximeter is essential prior to continuous jugular bulb oximetry. Sustained episodes of cerebral venous desaturation are frequent within the first 48 hours following acute head injury. Factors such as hypocapnia and cerebral hypoperfusion that primarily reduce cerebral blood flow are predominant.

Rehabilitation and splinting of common upper extremity injuries in athletes

Treatment of athletes and the injuries they sustain can be both challenging and rewarding. Each individual case requires a careful examination of the physical symptoms and the process leading up to the injury. From this, one attempts to determine the appropriate course of treatment aimed at minimizing lost time from sports and to develop preventive strategies to promote healing and prevent future injury. Open communication between the athlete and his or her physician, therapist, trainer, and coach facilitates the most innovative and effective treatment strategies, enabling the best possible result following an athletic injury to the upper extremity.

Medical management of the diabetic patient during podiatric surgery

Diabetes mellitus commonly causes complications of the foot that can lead to surgery. The appropriate perioperative management of diabetic patients can reduce the morbidity and mortality associated with diabetic foot surgery and enhance wound healing. The authors review the effects of hyperglycemia, detail preoperative, intraoperative, and postoperative care, and describe anesthetic choices. An algorithm for management of hypoglycemia is offered.

Malignant fibrous histiocytoma: review and case report

Malignant fibrous histiocytoma (MFH) is a rare tumour of the spermatic cord. We present the second reported case in Australia and review the literature, discussing the recommended management and prognosis of this condition.

Propranolol fails to lower the increased blood pressure caused by cold air exposure

Cold air exposure stimulates a rise in mean arterial blood pressure (MAP) and plasma norepinephrine (NE). The specific contribution of the beta-adrenergic receptor to this pressor response is unknown. Therefore, we pretreated 12 normal men with placebo or a bradycardia-inducing amount of propranolol prior to exposing them to either 25 degrees C or 4 degrees C air. At 25 degrees C, propranolol pretreatment lowered heart rate (HR) and MAP. When we compared changes in MAP after their respective 30-min exposure at 25 degrees C and 4 degrees C, the cold elevated MAP by 18.4 +/- 1.5 mm Hg in subjects pretreated with propranolol compared with 13.0 +/- 2.5 mm Hg in subjects pretreated with placebo. Fingertip skin temperature (Tfing) measured at 4 degrees C, 9.5 +/- 0.8 degrees C in propranolol-pretreated subjects was lower than the 11.1 +/- 0.7 degrees C with that of placebo. Plasma NE increased equally during cold exposure with both placebo and propranolol pretreatment. We conclude that the beta receptor plays a minor role in generating the pressor response to cold air. Therefore, the effectiveness of acute administrations of propranolol for maintaining normotension in subjects exposed to cold environments may be attenuated.

Adrenergic responses to cognitive activity in a cold environment

Adrenergic responses during physical stress such as cold exposure have been reported to differ from those responses observed during cognitive activity. Both the separate and the combined effects of cold and cognitive activity on catecholamine activity were examined in six male subjects. Alterations in plasma epinephrine and norepinephrine showed different patterns as a function of exposure to a 4 degrees C cold environment, a cognitive performance assessment battery (PAB), and the two conditions combined. Plasma epinephrine was not altered by exposure to cold and only slightly increased by PAB performance when given at 23 degrees C. However, epinephrine was substantially elevated by exposure to combined cold and PAB. Heart rate changes paralleled observed changes in epinephrine. Norepinephrine release was predominantly increased by cold exposure and was not altered by PAB performance.

Oxygen saturation of brachial venous blood correlates with fingertip temperatures between 11 and 39 degrees C

The relationships between fingertip skin temperature (Tfin), brachial venous hemoglobin oxygen saturation (SVO2), and plasma catecholamines were studied by exposing 15 semi-nude men to 30 min of 5 degrees C and 48 degrees C ambient air temperature extremes. After 30 min of cold air, norepinephrine (NE) increases from 2.01 +/- 0.26 to 7.15 +/- 0.64 nmol/L, and epinephrine (Epi) increases from 201 +/- 25 to 295 +/- 34 pmol/L. In contrast, after 30 min of hot air exposure, Epi rises from 161 +/- 32 to 348 +/- 43 pmol/L, while NE rises slightly from 2.07 +/- 0.26 to 2.57 +/- 0.64 nmol/L. Heat elevates SVO2 from 68.8 +/- 0.72 to 93.3 +/- 0.66% and Tfin from 29.5 +/- 1.09 to 39.4 +/- 0.56 degrees C. Cold lowers SVO2 to 32.1 +/- 0.70% and Tfin to 11.5 +/- 0.55 degrees C. SVO2 correlates with Tfin (r = 0.895, p less than 0.0001). We conclude that exposure to an environmental temperature of 5 degrees C decreases Tfin with concurrent decreases in blood flow and SVO2 in the extremity by the vasoconstrictive action of NE. Exposure to 48 degrees C increases Tfin with increases in blood flow and SVO2 in the extremity by vasodilation of peripheral vascular beds, which may be related to the rise in the plasma concentration of Epi.

Radio frequency (13.56 MHz) energy enhances recovery from mild hypothermia

The rate of warming after hypothermia depends on the method of rewarming. This study compared the effectiveness of radio frequency (RF) energy against hot (41 degrees C) water immersion (HW) and an insulated cocoon (IC) for rewarming hypothermic men. Six men fasted overnight and were rewarmed for 1 h after attaining a 0.5 degree C reduction in rectal temperature (Tre). Tre and esophageal (Tes) temperature were recorded every 5 min with nonmetallic thermal probes. The base-line value for Tre and Tes just before rewarming was subtracted from each 5 min Tre and Tes during rewarming to give delta Tre and delta Tes. The 12 delta Tes values were averaged for each individual and were compared using analysis of variance. The average delta Tes for RF (1.15 +/- 0.22 degrees C/h) was faster (P less than 0.001) than either IC (0.37 +/- 0.16 degrees C/h) or HW (0.18 +/- 0.09 degree C/h). The present study shows the superiority of RF energy for rewarming mildly hypothermic men.

Stimulation of glucose uptake in skeletal muscle using bolus or continuous insulin delivery

We investigated glucose uptake in the non-cyclically perfused rat hindlimb in response to continuous infusion (CI) or bolus injection (BI) of insulin. Ten mM glucose was infused at 3 ml/min, venous glucose was monitored at two minute intervals, and glucose uptake was calculated on the basis of arteriovenous-difference and expressed as micron/min/100 g body wt. Insulin BI given every ten minutes equaled the amount of insulin given by CI for ten minutes. Insulin doses of 1500, 3000, 6000, and 45,000 microU/30 min showed no significant difference between the two modes of delivery in either onset of stimulation or maximal stimulation of glucose uptake. At the lowest insulin dose tested (1500 microU/30 min) neither BI nor CI stimulated glucose uptake above the control of 1.849 micron/min/100 g. A dose response curve for glucose uptake was obtained using insulin boluses ranging from 2000 to 20,000 microU. Insulin uptake by the muscle was always greater when insulin was administered CI. Net disappearance of immunoreactive insulin over the entire 30 minutes of perfusion was 29.4 +/- 2.6% for CI but only 7.1 +/- 1.6% for BI. Thus in the perfused rat hindlimb, stimulation of glucose uptake in skeletal muscle is comparable with BI and CI delivery of insulin but insulin uptake by the muscle is several-fold greater with CI delivery.

Histologic evaluation of new attachment in humans. A preliminary report

This study was designed to evaluate the potential for regeneration of a new attachment (alveolar bone, cementum and a functional periodontal ligament) in patients whose attachment apparatus had been destroyed by periodontal disease. In each of the three parts of the investigation, the most apical level of calculus on the root served as a histologic reference point to measure regeneration. In Part I, attempts were made to initiate the formation of a new attachment by surgical debridement, crown removal (coronectomy) and submersion of the vital root below the mucosa. Nonsubmerged, surgically debrided defects served as controls. In Part II, debrided intrabony defects were treated with and without demineralized freeze-dried bone allograft and the associated vital roots were submerged. Part III evaluated potential for regeneration of a new attachment in nonsubmerged roots with and without the use of demineralized freeze-dried bone allograft. Gingival grafts were placed over the experimental and control sites in an attempt to retard epithelial migration. Biopsies were obtained in 6 months and regeneration was evaluated histometrically. Preliminary results in 7 patients and 24 intrabony defects indicate that new attachment is possible on pathologically exposed root surfaces in a submerged environment with and without the incorporation of demineralized freeze-dried bone allografts. New attachment was observed on pathologically exposed root surfaces in a nonsubmerged environment when intrabony defects were grafted with demineralized freeze-dried bone allograft. New attachment was not observed on nongrafted, nonsubmerged, defects with and without the placement of gingival grafts over the defects.

Diuretic regimens in essential hypertension. A comparison of hypokalemic effects, BP control, and cost

Intolerable side effects and hypokalemia during thiazide treatment of hypertension frequently necessitate a change in diuretic regimen. The hypokalemic effects, effectiveness in controlling BP, and cost of several alternate diuretic regimens were evaluated. Prevalences of serum K+ values less than 3.5 mEq/L were as follows for the various regimens: hydrochlorothiazide, 50 mg daily, 11.0% (n = 500); chlorthalidone, 25 mg daily, 8.1% (n = 37); triamterene, 100 mg, plus hydrochlorothiazide, 50 mg daily, 5.3% (n = 357); hydrochlorothiazide, 25 mg daily, 2.2% (n = 183); and furosemide, 40 mg daily, 3.5% (n = 284). In paired studies comparing hydrochlorothiazide with alternate diuretic regimens, potassium conservation was comparable with furosemide, the triamterene/hydrochlorothiazide combination, the spironolactone/hydrochlorothiazide combination, and adding potassium, 37 mEq daily. All alternate diuretic regimens were as effective as hydrochlorothiazide in controlling BP. Furosemide reduced serum glucose and calcium levels compared with hydrochlorothiazide. When these factors and costs are considered, furosemide appears to be the most cost-effective alternative in patients with hypertension in whom intolerable side effects or hypokalemia develops while taking hydrochlorothiazide.

Dose-related influence of indomethacin on parathyroid hormone-stimulated adenosine 3',5'-monophosphate release from the perfused rat hindlimb

We examined the effect of indomethacin (INDO) on PTH-stimulated cAMP release from the perfused rat hindlimb. Since this preparation has not been used previously to study the effects of PTH, we first determined the dose-response curve for cAMP release in response to the 1-34 fragment of synthetic bovine PTH. cAMP release peaked 3-6 min after the PTH bolus and declined gradually toward baseline, even with sustained PTH infusion. The rate of cAMP release was directly related to the PTH dose. The lowest PTH priming dose that provoked a significant increase in cAMP release was 0.6 IU. Maximal cAMP release, occurring in response to a PTH priming dose of 30 IU, was 3- to 4-fold greater than baseline. PTH caused no increase in cAMP release from or the cAMP content of isolated skeletal muscle in vitro, suggesting that cAMP released from the hindlimb in response to PTH is derived solely from bone. PTH-stimulated cAMP release was unaltered by pretreatment of the intact rat with 2 mg/kg INDO, a dose that blocks prostaglandin synthesis. In contrast, PTH-stimulated cAMP release was significantly attenuated by pretreatment with 75 mg/kg INDO. The effect was not dependent on the addition of drug to the perfusate and was not altered by thyroparathyroidectomy at the time of INDO administration. We conclude that 1) the perfused rat hindlimb can be used to examine PTH effects on bone; 2) 2 mg/kg INDO has no effect on PTH-stimulated cAMP release from the perfused rat hindlimb; and 3) INDO in high doses blunts PTH activation of adenylate cyclase.

Hemoglobin A1 correlates with the ratio of low-to high-density-lipoprotein cholesterol in normal weight type II diabetics

Because cardiovascular risk correlates with serum low density lipoprotein (LDL) cholesterol and is inverse with high density lipoprotein (HDL) cholesterol, the LDL-HDL cholesterol ratio has been advocated as a sensitive index of relative cardiovascular risk. In 50 normal weight insulin-treated Type II diabetic subjects, mean LDL-HDL ratios were significantly higher than for controls. In diabetic women, the LDL-HDL cholesterol ratio correlated with hemoglobin A1 better than any of the lipids or lipoprotein cholesterol fractions. When 8 poorly controlled diabetics were treated with insulin, the LDL-HDL ratio changed more significantly than did its component fractions, and the fall in LDL-HDL ratio paralleled the fall in hemoglobin A1.

Serum lipid changes after estrogen therapy in prostatic carcinoma

A study of serum lipid fraction changes in 15 estrogen-treated patients with carcinoma of the prostate is conducted. Estrogen therapy is known to be associated with cardiovascular complications. certain serum lipid fraction changes, particularly elevated low-density lipoprotein (LDL) and decreased high-density lipoprotein (HDL), are known to increase the risk of cardiovascular diseases. In our study, decrease in total cholesterol, increase in triglycerides, decreased LDL, and LDL/HDL ratio in combination with elevated HDL fraction suggest that the lipid changes are not the mediators of above complications.

Urinary estriols: are they of value in normoglycemic diabetic pregnancy?

The purpose of the study was to assess the value of 24-h urinary estriols in the management of diabetic pregnancies. Twenty-seven pregnant diabetic patients (White's class B through R) received insulin dosages twice daily as a combination of NPH and regular insulin. Laboratory and home monitored blood glucose was maintained within the range of 70-150 mg/dl. From 32 wk onward daily 24-h urinary estriols, weekly fetal heart rate monitoring, and, when indicated, amniotic fluid lecithin/sphingomyelin ratio were used to evaluate fetal well-being. Fetal heart rate and amniotic fluid testing were of value while urinary estriols failed to be useful in management or timing of delivery. We conclude that when third-trimester normoglycemia is maintained in pregnant diabetic patients, one obviates the need for the costly and odious task of daily urine estriol measurements.

Acute tolbutamide administration alone or combined with insulin enhances glucose uptake in the perfused rat hindlimb

We examined the effects of acute administration of tolbutamide on glucose uptake in the non-cyclically perfused rat hindlimb. During the hour of study, 500 microunits boluses of insulin were given every ten min in the presence or absence of 3 X 10(-3)M tolbutamide. Tolbutamide by itself increased glucose uptake; however at no time was this increase significantly different from that seen in the group which received insulin alone. After 42 min of perfusion, the insulin-stimulated uptake was 26% and the tolbutamide was 20% greater than control (1.90 +/- 0.08, 1.80 +/- 0.06, and 1.50 +/- 0.05 mumol/min/100 g respectively). After 20 min of perfusion, the increase in glucose uptake seen with the combination of insulin + tolbutamide was significantly greater than that obtained with either tolbutamide or insulin alone. At the termination of perfusion, the glucose uptake with the combined treatment was 59% greater than control, 35% greater than tolbutamide, and 19% greater than insulin alone (2.67 +/- 0.10, vrs. 1.68 +/- 0.07 vrs. 1.97 +/- 0.07 vrs. 2.16 +/- 0.07 mumol/min/100 g). These results demonstrate not only a direct effect of tolbutamide, but also a potentiation of insulin-stimulated glucose uptake in the rat hindlimb. Therefore, tolbutamide has extra-pancreatic effects which probably contribute to the hypoglycemic action of this sulfonylurea.

Effects of pharmacologic hyperglucagonemia on plasma amino acid concentrations in normal and diabetic man

Four normal and five insulin dependent diabetic men received a 2 h pharmacologic glucagon infusion (50 ng/kg/min) resulting in plasma glucagon levels (4400 pg/ml) similar to those seen in glucagonoma patients. In normal subjects in whom plasma insulin concentrations rose significantly (239 uU/ml) and the blood level of 15 of the 18 amino acids measured fell significantly. In contrast, in the diabetic men who secreted no insulin in response to glucagon (no rise in C-peptide levels), only 10 of 18 amino acid levels fell significantly. The branched chain amino acids valine, leucine and isoleucine, as well as tyrosine and phenylalanine were among the 8 amino acids which showed no change in response to glucagon in the diabetics. Thus, glucagon appears to have no acute affect on branched chain amino acid levels in man.

Predicting client improvement from and satisfaction with community mental health center services

The present study assesses client improvement from and satisfaction with CMHC services, and attempts to examine the presence of positive bias from responders. Results based on questionnaires mailed to 1,000 former clients indicated both high consumer satisfaction and reported improvement attributable to treatment. Responders and nonresponders did not differ on demographic or treatment variables related to post-treatment improvement. A multiple regression analysis was computed and yielded an estimated index of improvement for responders. No differences obtained on this measure between responders and nonresponders, thereby not supporting the presence of a positive bias in this sample. confidence in therapist, satisfaction with the therapeutic relationship, and number of individual sessions were the most positive improvement correlates, with lack of contact and increasing age most negatively related to improvement. Discussion focuses on the implications for generalization of results based on responders' data.

Effect of sulfonylurea therapy and plasma glucose levels on hemoglobin A1c in type II diabetes mellitus

It is well known that hemoglobin A1c reflects plasma glucose concentrations in patients with diabetes mellitus. To examine hemoglobin A1c and plasma glucose relationships in sulfonylurea-treated patients, 25 patients with well-controlled type II diabetes (fasting plasma glucose 128 +/- 6 mg/dl, hemoglobin A1c 7.6 +/- 0.5 percent) were evaluated in a double-blind study. This study was divided into two phases (periods I and II). During period I each patient was given a diet plus a placebo and was followed every two weeks until the mean of two consecutive plasma glucose determinations was more than 50 mg/dl above the initial plasma glucose concentration obtained while the patient was taking sulfonylurea. At that point each patient was switched in a double-blind fashion to either diet plus a placebo or diet plus tolazamide. Fasting plasma glucose concentrations increased to 178 +/- 9 mg/dl (p less than 0.005) for all patients by week 2 of period I. The increase in hemoglobin A1c concentration was seen to lag behind the increasing fasting plasma glucose concentration by four to six weeks. Fasting plasma glucose and hemoglobin A1c concentrations returned to values indistinguishable from initial values in patients who were given tolazamide and who responded to it. A positive correlation was noted when the hemoglobin A1c concentration was compared with the fasting plasma glucose concentration measured four to six weeks previously.

Avoidance of surgical hyperglycemia in diabetic patients

Strict intraoperative glucose level control was accomplished with constant low-dose glucose infusion of 100 mg/kg/hr and variable infusion rates of insulin to control serum glucose levels as follows: 20 units/hr for serum glucose levels greater than 200 mg/dL, 1 unit/hr for levels between 80 and 200 mg/dL, and no insulin for levels less than 80 mg/dL. Using this technique, eight diabetic patients with serum glucose levels greater than 250 mg/dL before surgery had their serum glocose levels brought rapidly under control (ie, glucose level less than 200 mg/dL), which continued postoperatively.

Prolonged effect of insulin on glucose uptake by rat skeletal muscle

The fate of insulin, as it relates to its action on skeletal-muscle glucose uptake, was studied in non-cyclically perfused rat hindlimbs. Insulin (1m-i.u./ml) with and without (125)I-labelled insulin was infused intra-arterially for 5 or 6min. Net glucose uptake and the release of (125)I-labelled insulin into the venous effluent were evaluated by arteriovenous-difference measurements for an additional 24-32min. The infusion of insulin for 5min promoted glucose uptake, an effect that persisted throughout a subsequent 25min of perfusion in the absence of insulin. The addition of insulin antibody to the perfusate in the presence of insulin blocked the action of insulin on glucose uptake, but it failed to alter insulin action if the muscle tissue had been exposed to insulin before addition of antibody. When (125)I-labelled albumin was infused for 6min, venous effluent radioactivity decayed rapidly and remained HClO(4)-insoluble and there was no significant tissue retension of radioactivity. Comparable experiments in which (125)I-labelled insulin was infused for 6min revealed that the venous effluent radioactivity decayed more slowly, a significant amount of the (125)I-labelled insulin appeared as fragments (HClO(4)-soluble) and there was a significant retention of radioactivity in the tissue. Radioactivity in muscle tissue biopsies obtained 28min after infusion of (125)I-labelled insulin was associated largely with intact insulin and a peptide of mol.wt. 2400. The total radioactivity retained in the muscle at this time was 7% of the amount infused. An insulin bolus (1i.u.) failed to increase the discharge of this tissue-associated radioactivity. These results suggest that insulin and a product of insulin metabolism persists in muscle tissue long after the arterial presence of insulin ends. This tissue residence and processing of insulin may be important components of insulin's prolonged action on glucose uptake by skeletal muscle.

Insulin therapy for gestational diabetes

Seventy-two patient with gestational diabetes were randomly treated with insulin (20 units NPH and 10 units regular) and diabetic diet, diet alone, or neither. Of the 27 patients treated with insulin and diet, 2 (7%) had babies weighing more than 8 1/2 pounds. Of the 11 patients treated with diet alone, 4 (36.4%) had babies weighing more than 8 1/2 pounds. Of the 34 patients treated with neither diet nor insulin, 17 (50%) had babies weighing more than 8 1/2 pounds. These data support the hypothesis that treatment of the gestational diabetic with insulin will reduce the incidence of fetal macrosomia.

Glucose delivery: a modulator of glucose uptake in contracting skeletal muscle

To evaluate glucose delivery and neuromuscular activity as modulators of glucose uptake in skeletal muscle, rat hindlimbs from pentobarbital-anesthetized rats were perfused in the presence of electrically stimulated muscular contractions. Glucose delivery was varied by altering non-cyclic perfusate flow. When flow was increased from 3 to 12 ml/min glucose disappearance increased from 1.1 +/- 0.2 to 4.0 +/- 0.2 mumol/min per 100 g rat (P less than 0.001). When glucose delivery was held constant, glucose disappearance was unaltered during muscular contractions. Insulin enhanced glucose disappearance, and its effect was unaltered during muscular contractions. Muscular contractions increased oxygen disappearance by two- to 3.5-fold and lactate appearance by 4.5- to fivefold (P less than 0.02). It was concluded that glucose delivery and insulin modulate glucose disappearance in isolated perfused rat hindlimbs. Electrical stimulation of muscle enhances lactate appearance and oxygen disappearance but does not alter glucose disappearance when flow is held constant. Because blood flow to muscle increases during exercise in vivo, increased glucose delivery may be a modulator of the augmented muscle glucose consumption observed under these conditions.

Endocrine and metabolic alterations with food and water deprivation

Two healthy men were evaluated before and after a 56-day raft voyage to determine endocrine and metabolic status immediately after and during the recovery phase after long-term caloric, protein, and water deprivation. Daily intake during the trip consisted of no protein, 300 ml water, and for the first 40 days, 300 kcal glucose. The subjects lost weight from 84.1 to 58.1 and 78.3 to 57.7 kg, respectively. Significant variations included: 1) decreased excretion and loss of diurnal pattern of 17-hydroxycorticoids with normal serum corticoid levels and variation; 2) decreased serum testosterone levels and concomitant low follicle stimulating hormone and low normal luteinizing hormone levels; 3) decreased urinary 17-ketosteroid levels; 4) low plasma insulin levels with normal serum glucose concentrations; 5) increased triglyceride content in the 1.006 less than d less than 1.063 lipoproteins during fasting with a marked increase in high density lipoprotein cholesterol upon refeeding. The percent content of the R-serine (C-I) apoprotein among the soluble apoproteins of very low density lipoproteins diminished markedly during the fast; 6) abnormal liver function immediately after fasting with increased abnormality after the 2 weeks of refeeding and return to normal by 6 weeks; 7) normal fat and xylose absorption, normal estradiol, estrone and prolactin levels, and renal function studies.

Peripheral diabetic neuropathy treated with amitriptyline and fluphenazine

The pain of diabetic peripheral neuropathy responds poorly to current modes of treatment. We treated eight patients with this disorder whose pain was refractory to standard regimens but who experienced remarkable pain relief within two to five days after treatment with fluphenazine hydrochloride, amitriptyline hydrochloride, or a combination of the two. In four patients whose regimens were discontinued, pain recurred within two days and again remitted on reinstitution of the drug regimens. These findings suggest that fluphenazine alone or in combination with amitriptyline may be of benefit in treating the painful peripheral neuropathy associated with diabetes.

Clinical evaluation of somatostatin as a potential ajunct to insulin in the management of diabetes mellitus

To determine whether somatostatin, an inhibitor of glucagon and growth hormone secretion, might be useful as an adjunct to insulin the management of diabetic hyperglycaemia, seven insulin-requiring diabetic men were given somatostatin (100 microgram/h, IV) continuously for 3 days after their diabetes had been treated intensively by diet and insulin on a metabolic ward. During infusion of somatostatin and despite reduction in average insulin dose exceeding 50%, there was improvement in diabetic control as assessed by postprandial hyperglycaemia, 24-h glycosuria and the average daily serum glucose level and its fluctuation; when somatostatin was discontinued, but insulin doses held constant, diabetic control rapidly worsened. No adverse effects were observed. These results indicate that somatostatin plus insulin can be a more effective regimen than insulin alone in controlling diabetic hyperglycaemia. A longer acting and more selective somatostatin preparation may prove useful as an adjunct to insulin in the management of diabetes.

Insulin-glucose dynamics during flow-through perfusion of the isolated rat hindlimb

The dose-response relationship between glucose and insulin concentration and utilization in skeletal muscle was examined in hindlimbs of overnight fasted normal male rats. The perfusion was by flow-through technique utilizing an artificial perfusate containing beef erythrocytes. Glucose disappearance correlated significantly with insulin concentration. Insulin effect was detected within 5 minutes. When arterial glucose was 10 mM, glucose disappearance during maximal insulin stimulation was fivefold greater than glucose disappearance in the absence of insulin. A half-maximal effect occurred at an insulin concentration of 411 U per ml. Arteriovenous difference of immunoreactive insulin during a single passage thorugh the hindlimb averaged 16.7% over the range of 50 to 10,000 U per ml. In the presence or absence of insulin, glucose disappearance was positively correlated with glucose concentration up to a glucose concentration range of 30 to 45 mM. In this range and above glucose uptake averaged twelvefold above that observed for 5 mM glucose. When insulin (500 muU/ml) was added at any glucose concentration, glucose disappearance was augmented. The data thus indicate that rat skeletal muscle is a major site of insulin metabolism. In addition to the effect of insulin on glucose uptake by the muscle cell, glucose mass action appears to be quantitatively equipotent.