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Objective: To compare the distribution and observation of helmet use patterns among 4 common childhood leisure activities-bicycle riding, in-line skating, skateboarding, and scooter riding-in a setting with no helmet use legislation., Design: A cross-sectional, unobtrusive, direct observation of children engaged in 1 of the 4 activities was conducted during an 8-week period., Setting: Eight communities of at least 1000 persons each in a 2-county Central Texas area., Main Outcome Measures: Prevalence of activity, helmet use, and correct helmet use., Results: Of 841 children observed, most rode bicycles (74.8%); only 4.2% rode skateboards. They included 127 children estimated to be younger than 6 years (15.1%) and 495 estimated to be aged between 6 and 12 years (58.9%). Most were male (67.3%) and observed in urban communities (61.7%). The locations of highest concentration of the 4 activities were minor streets for bicycle riding, playgrounds for in-line skating, and sidewalks for skateboarding and scooter riding. The rate of overall helmet use was 13.6% and did not vary significantly by activity: in-line skating, 18.2%; skateboarding, 14.3%; bicycle riding, 13.5%; and scooter riding, 11.5%. However, the observed correct helmet use prevalence of 72.6% differed significantly by activity. Most children riding scooters wore their helmets incorrectly. Helmet use was positively associated with helmet use by accompanying children and/or adults., Conclusions: While bicycle riding was the most popular activity observed, helmet use was most prevalent among in-line skaters and least prevalent among scooter riders, many of whom also wore them incorrectly. Observed helmet use was influenced mostly by adult and peer helmet use, indicating that public education and interventions should target children and their parents as well as scooter riders.

A novel technique of application of controlled ventral scald burn to rodent, whose back is inaccessible because of preburn preparation, is described. Boiling water is applied across a polyethylene membrane that partially envelops the subject. The technique is simple, economical, reproducible and allows intravital microscopic study of microcirculation in a remote muscular bed before and after burn injury.

Coricidin products seemed to be one of the over-the-counter medications being reportedly abused by adolescents, as observed from the Texas Poison Center Network data. This retrospective chart review investigated the occurrence of abuse, developed a patient profile, and defined the clinical effects resulting from the abuse of Coricidin products. Data collected from the Texas Poison Center Network Toxic Exposure Surveillance System database included human exposures between 1998 and 1999, patients > or = 10y old, intentional use or abuse, and single substance ingestion of I of the tablet formulations of Coricidin. Thirty-three cases from 1998 and 59 cases from 1999 were reviewed. Of these cases, 85% met the inclusion criteria. Of the 7 medications searched, only 4 substances were coded for: Coricidin D, Coricidin D (long acting), Coricidin D (cold, flu & sinus) and Coriciding HBP. These contain a combination of dextromethorphan hydrobromide, chlorpheniramine maleate, phenylpropanolamine hydrochloride, and acetaminophen. Of the 78 cases, 63% were male and 38% were female. The mean age was 14.67 years, 77% being between 13 to 17 years old. Eighteen different symptoms were reported: tachycardia 50%, somnolence 24.4%, mydriasis and hypertension 16.7%, agitation 12.8%, disorientation 10.3%, slurred speech 9%, ataxia 6.4%, vomiting 5.1%, dry mouth and hallucinations 3.9%, tremor 2.6%, and headache, dizziness, syncope, seizure, chest pain, and nystagmus each 1.3%; 12.8% of the calls originated from the school nurse. The incidence of abuse reported increased 60% from 1998 to 1999. This worrisome trend suggests increased abuse of these products.

Objectives: To compare the sensitivity and negative predictive values of frozen section analysis of pelvic lymphadenectomy in patients undergoing radical retropubic prostatectomy for prostate adenocarcinoma with the predictive power of published nomograms for metastasis to lymph nodes., Methods: A retrospective review was performed on all patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for prostate adenocarcinoma between 1991 and early 1997. The sensitivity and negative predictive values were computed comparing frozen section analysis, and patients were grouped by risk stratification. Comparison was made using the McNemar text., Results: The sensitivity for detecting lymph node metastasis on frozen section analysis for all risk groups was 33% (9 of 27). The sensitivity for identifying patients at high risk of having nodal metastasis by published nomograms alone was 67% (18 of 27) (P = 0.04). The overall negative predictive value for frozen section analysis was 96.5% (503 of 521). The negative predictive value for uninvolved lymph nodes, using low and intermediate-risk groups stratified by published nomograms, was 97.9% (436 of 445)., Conclusions: Frozen section analysis of pelvic lymph nodes to detect metastatic prostate adenocarcinoma is less sensitive in determining which patients will have lymph nodes involved by metastatic adenocarcinoma than using risk stratification by published nomograms. The negative predictive value of frozen section analysis in all risk groups was very high, up to 97.9%.

Influenza virus infection can cause an acute exacerbation of asthma that may result in hospitalization. Annual influenza vaccination is recommended for children with asthma, but fewer than 10 percent receive it. This review summarizes the influenza-associated morbidity in children with asthma. The risk-versus-benefit of influenza vaccination in children with asthma is evaluated. Strategies to improve influenza vaccine uptake in children with asthma are investigated. Influenza virus infection causes substantial morbidity in children with asthma. Data on safety and effectiveness of the trivalent influenza vaccine in these children are limited. However, it is generally safe and effective in preventing influenza infection. The investigational live-attenuated, cold-adapted, trivalent nasal spray influenza vaccine needs evaluation for safety and efficacy in children with asthma. An annual, well-organized, computerized multicomponent strategy should be implemented for optimizing influenza immunization in the high-risk population. Children with asthma should be targeted for annual influenza immunization.

Background/purpose: Laparoscopic Appendectomy (LA) is a safe procedure in adults resulting in shorter hospitalization and sooner return to activity. The relative merits of LA and open appendectomy (OA) are evaluated in this first prospective and randomized study in children., Methods: A total of 129 children with appendicitis were included. Forty-three boys and 45 girls, age 1 to 16 years, were enrolled. Randomization was determined by sealed assignment card. OA utilized a 3- to 4-cm right lower quadrant, muscle-splitting incision. Wounds were closed without drains. Antibiotics, when used, consisted of gentamycin, clindamycin, and ampicillin. LA was performed by experienced surgeons utilizing a 3-trocar technique with reusable instruments. Twenty-one children (24%) were perforated. Patients were discharged as soon as they were taking a diet and afebrile. Statistical comparisons were by Fisher's Exact and Wilcoxon rank-sum tests., Results: There were no differences in postoperative analgesia, resumption of oral intake, length of hospitalization, return to normal activities, or morbidity. Laparoscopic appendectomy was associated with longer operating times and increased cost., Conclusions: Laparoscopic appendectomy in children is not associated with the same advantages reported in adults. LA is a more expensive alternative and offers no advantages related to pain relief, length of stay, return to normal activities, or morbidity., (Copyright 2002 by W.B. Saunders Company.)

Approximately 190 new cases of renal cell carcinoma infiltrate into the inferior vena cava and right atrium every year. Echocardiography often plays a major role in establishing the diagnosis and in guiding surgical therapy. This report describes a patient who presented with shortness of breath but had no classic signs or symptoms of renal cell carcinoma other than chronic anemia. Transthoracic two-dimensional echocardiography and transesophageal echocardiography established the diagnosis of a right atrial mass extending from the inferior vena cava that was later discovered to be renal cell carcinoma.

Surface antigen CD69 is a Type II integral membrane protein that is generally considered a cell activation marker expressed very early in the normal lymphocyte activation cascade. The conformation of this surface antigen suggests a putative role in transmembrane signal transduction, yet the precise function of this surface antigen has not been clearly elucidated. We had previously reported robust atypical CD69 expression in peripheral T-lymphocytes as concentration-dependent, phenotypic responses to actinomycin D-induced chemotherapeutic stress in the absence of secondary stimulation. Additional antitumor antibiotics were evaluated for inductive potential, and the incidence and respective magnitudes of this chemotherapeutic stress-induced shift in lymphocytic CD69 expression were assessed. Results indicated that atypical CD69 expression is a common response to chemotherapy drug-induced stress. Differences in the respective percentages of CD69 + T-lymphocytes, and the resulting numbers of CD69 surface antigens ultimately expressed by these cells, were documented following in vitro drug exposure. The effective drug concentrations required to mediate detectable shifts in the CD69+ phenotype differed among the selected drugs, as well, suggesting a concentration-dependent induction mechanism putatively related to drug modality. Static CD69 expression responses in CD3+ peripheral T-lymphocytes were also documented, which further suggests that the different intracellular modalities do not mediate proportional T-lymphocyte responses through elevated CD69 expression.

In acute coronary syndromes, GPIIb/IIIa platelet inhibitors have demonstrated a reduction in recurrent myocardial ischemia. Conversely, one might expect that enhancing platelet activity in patients in acute coronary syndromes would have the opposite effect. We report a patient with idiopathic thrombocytopenic purpura (ITP) that had recurrent myocardial ischemia associated with administration of intravenous immunogloblin (IVIG). Literature is reviewed.

Vocal cord dysfunction (VCD), an under appreciated cause of wheezing, may be mistaken for or coexist with asthma. The vocal cords involuntarily adduct during inspiration, leading to inspiratory or biphasic wheezing. Asthma therapy offers no benefit and may result in injury. Proof of diagnosis requires endoscopy during an episode. Definitive therapy involves voice training by a speech pathologist, but heliox (20% to 40% oxygen in helium) has been used to reduce symptoms, resulting in dramatic improvement in wheezing and less anxiety. A retrospective review of recent experience with heliox treatment for patients with VCD was conducted, using a search of computerized inpatient and outpatient physician dictation reporting at Scott & White Memorial Hospital and Clinic. Five patients age 10 to 15 years were treated with a favorable response in four. There were no complications of therapy. A high index of suspicion can lead to the diagnosis of VCD, avoiding expensive, inappropriate, and harmful therapy. A trial of heliox inhalation for patients with symptomatic VCD may prove beneficial, analogous to the "reliever" role of beta agonists for asthma. Home or school use of heliox may reduce acute care visits, while voice training ("controller" therapy) is instituted.

Background: Influenza virus infection frequently triggers asthma exacerbation and hospitalization. Annual influenza immunization is recommended for children with chronic conditions, including those with asthma or reactive airway disease (RAD); however, <10% receive it each year., Methods: In September, 1997, we instituted a computerized staged reminder strategy for annual influenza immunization of children with asthma/RAD at the Scott and White Pediatric Clinic in Temple. A reminder letter, followed six weeks later by an autodial recall telephone message, was sent to the parent/guardian of children with asthma/RAD using the Shared Medical Systems to identify children with asthma/RAD and the Integrated Client Encounter System to record immunizations. The effect of this computerized reminder system on the influenza immunization rate of a cohort of 925 Scott and White Pediatric Clinic children with asthma/RAD was examined for the 1996 to 1997 and 1997 to 1998 influenza seasons, before and after intervention., Results: A significant increase in influenza immunization rate from 5.4% to 32.1% occurred in all age groups, regardless of the insurance status. The medically attended acute respiratory illness rate per 100 subjects was significantly higher in vaccinated than in unvaccinated children for each of the two influenza epidemics and in the period between the two epidemics., Conclusion: A computerized reminder letter followed by an autodial recall telephone message is effective in increasing the influenza immunization rate of children with asthma/RAD. Children with significantly higher respiratory morbidity during and in between two influenza epidemics were more likely to be immunized after receiving written and telephone autodial reminders.

The case of a patient with a prosthetic aortic valve and warfarin hypersensitivity is presented. On rechallenging the patient with warfarin, a spongiotic dermatitis with heavy superficial perivascular lymphocytic infiltrates with eosinophils was seen. The patient was finally discharged on aspirin therapy alone and is doing well to date. Warfarin hypersensitivity is rare, and only incidental reports exist regarding its incidence and management. It is conceivable that newer antiplatelet agents, whether alone or in combination with aspirin, will provide better control of thromboembolic events in patients with warfarin intolerance.

Generalised weakness is a common complaint. A case is presented of toluene induced hypokalaemia in a 22 year old woman who presented with generalised weakness. The effect of toluene and causes of weakness and hypokalaemia in this setting are discussed.

A 36-year-old man captured a timber rattlesnake and was accidentally envenomated in the thumb by the severed head. At a local emergency department, hypotension and confusion developed. Facial and glossal edema were also observed. Oxygen was delivered by face mask, and crystalloids and dopamine were administered. Respiratory distress developed with progressive hypoxemia. Intubation was unsuccessful because of massive glossal and epiglottic (laryngeal) edema, and an emergency cricothyrotomy was performed. High-dose antivenom therapy was administered, and mechanical ventilation was started. Recovery was rapid, and the patient was discharged from the hospital a week later. This is the first report of life-threatening upper airway edema caused by snake envenomation not in the vicinity of the head or neck.

We describe a case of low-grade myxofibrosarcoma with the karyotype 46,XX,t(2;15)(p23;q21.2), del(7)(q?11.2q?22). Only six of these tumors have been previously studied and all were cytogenetically different.

Pericardial tamponade is a rare complication of acute myocardial infarction. The authors present the case of a patient with a large anterior myocardial infarction administered thrombolytics who developed postinfarction pericarditis. Because of a stuttering course with concomitant postinfarction angina, urgent angiography, leading to percutaneous transluminal coronary angioplasty and stent implantation, was performed. Administration of abciximab prior to percutaneous transluminal coronary angioplasty appears to have precipitated pericardial tamponade. The authors review the literature concerning numerous commonly utilized therapeutic options that could have contributed to the development of pericardial tamponade.

A 29-year-old woman presented with shortness of breath, vague chest pain, and prominent intermittent ejection systolic murmur. Transthoracic echocardiography showed a large mass in the right ventricular outflow tract. Transesophageal echocardiography demonstrated two masses that were adherent to the tricuspid valve and intermittently prolapsed through the pulmonary valve. Computed tomography of the chest corroborated the echocardiographic findings. Currently, there are no definitive guidelines regarding the optimal management of right heart thrombi in patients with antiphospholipid syndrome. Our patient did not respond to a standard dose of rt-PA used in the treatment of pulmonary embolus. She underwent successful surgical resection of the thrombi without complications.

Objective: Many health care providers and patients are exploring the feasibility of using E-mail to address a variety of medical issues. The researchers wanted to determine the proportion of their patient population with E-mail access, determine patients' willingness to use this technology to expedite communication with health care providers, and assess their expectations of response times., Study Design: A cross-sectional, in-person prevalence survey., Population: Patients (n=950) with scheduled appointments to see a primary care provider in 6 of 18 family practice clinics in a large health care delivery system in central Texas., Outcomes Measured: The proportion of patients with E-mail access, their willingness to use it, and their expectations regarding the timeliness of responses to their E-mail queries about selected clinical services., Results: Overall, 54.3% of the patients reported having E-mail access, with significant variation among the 6 clinics (33%-75%). Reported areas of strongest desire for using E-mail were to request prescription refills (90%), for non-urgent consultations (87%), and to obtain routine laboratory results or test reports (84%). Patients' expectations regarding the timeliness of responses to their E-mail queries varied by clinical service. For laboratory results, their expectations were: less than 9 hours, 21%; 9 to 24 hours, 53%; and more than 24 hours, 26%., Conclusions: Most patients attending family practice clinics in central Texas have E-mail access and indicate they would use it to request prescription refills, for non-urgent consultations, and to obtain routine laboratory results or test reports. Regardless of sex or race, patients have high expectations that these tasks can be completed within a relatively short time.

A neurilemoma is an uncommon, benign, encapsulated neoplasm whose origin is derived from the Schwann cells. Its incidence in the foot is uncommon. A review of the literature, etiology, incidence, clinical presentation, histology, differential diagnosis, and treatment are discussed. The authors present a case of a neurilemoma of the medial plantar nerve of the foot.

Endoscopic ultrasound is useful for managing submucosal masses; however, some of these lesions can be difficult to classify except with full histological and electron microscopic evaluation. A 72-yr-old woman was seen with upper GI bleeding. Endoscopy showed a 1.7-cm sessile ulcerated submucosal mass in the duodenal bulb. Endoscopic ultrasound revealed an echolucent submucosal mass arising from the fourth echolayer, the muscularis propria of the duodenal wall. These findings suggested that the lesion was a leiomyoma. The patient eventually had the lesion resected because of recurrent bleeding. Histologically it was a spindle cell tumor that on electron microscopy showed neuronal elements consistent with a plexosarcoma, or gastrointestinal autonomic nerve tumor. These lesions account for some one third of all gastrointestinal stromal tumors. Despite their low grade malignant histologic appearance, local recurrence or hepatic metastases occur in about 70% of patients.

Hypothyroxinemia is a common finding in premature infants, presumably resulting from an immature hypothalamic-pituitary-thyroid axis. Because dynamic studies of thyroid function in premature infants are normal and the condition resolves spontaneously, HOP has been considered physiologic rather than pathologic. Thus, thyroid hormone supplementation has been assumed to be not required in premature infants. True hypothyroidism of hypothalamic pituitary or thyroid origin, however, does occur in premature as well as in term infants and should be investigated aggressively and treated appropriately. Current studies in premature infants with hypothyroxinemia suggest the following: infants with more than 27 weeks of gestation do not appear to benefit and may, in fact, be harmed by thyroid hormone supplementation; and short-term thyroid hormone supplementation in infants born before 27 weeks of gestation may be important to diminish morbidity and to improve neurodevelopmental outcome.

Objective: Although endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration have been shown to aid in the diagnosis and staging of pancreatic carcinoma, whether the general use of these new techniques impacts the overall management and survival of pancreatic cancer, is less clear., Methods: Clinical data on all patients diagnosed with pancreatic carcinoma were assessed for two equal time periods during which computerized tomography-guided fine needle aspiration and biopsy was used (1/93-5/95) and then during which endoscopic ultrasound-guided fine needle aspiration was used (8/95-12/97) for the primary diagnosis of these patients., Results: Comparative data for the computerized tomography era versus the endosonography era showed that 1) pancreatic carcinomas diagnosed: 52 versus 84 patients (stage I-III at diagnosis: 33% vs 54%; p < 0.05); 2) diagnosis by aspiration or biopsy of a pancreatic mass, nodes, liver metastasis, or by operation: 46%, 0%, 19%, 29% versus 52%, 8% (p = 0.02 nodes plus pancreatic masses), 20%, 7% (p = 0.002); 3) pancreatic resections: 13% versus 14%; 4) median survival without liver metastases: 102 versus 205 days (p < 0.02, log-rank test). Endoscopic ultrasound detected carcinomas that were either not seen or only possibly seen by computed tomography in 34%., Conclusions: More patients (62%) were diagnosed with pancreatic carcinoma when using endoscopic ultrasound and 75% fewer required operations for diagnosis. The 3-month improvement in median survival is probably multifactorial but most likely represents lead bias because of the greater sensitivity of endoscopic ultrasound for pancreatic carcinoma. Using endoscopic ultrasound with endoscopic ultrasound-guided fine needle aspiration in patients with pancreatic carcinoma significantly affects their management and outcomes.

Objective: This study was undertaken to determine the incidence, hospital charges, and correlates associated with inpatient treatment of child maltreatment related injuries., Methods: The data were based on the 1995 Pennsylvania Hospital Discharge Data which included all Pennsylvania acute care hospitals that reported child maltreatment discharges. Per capita hospital discharge rates were computed for children discharged with child maltreatment related injuries according to selected variables. Odds ratios for child maltreatment related injury hospitalizations were also computed., Results: A total of 348 maltreated injured children ages 0-19 years were discharged from Pennsylvania hospitals in 1995, representing an incidence rate of 10.8 per 100,000 persons. The total hospital charges for child maltreatment related injury discharges amounted to over $5.4 million, of which Medicaid alone paid for 45%. Compared to a random sample of non-maltreated injured children (n = 1052), maltreated injured children were found to be significantly younger, more likely to be females, and more likely to be Black. Child maltreatment related injury hospitalizations were more likely to be urgent and via physician referral or transfer from other health care facility. Maltreated injured children were three times as likely to die as other children., Conclusions: These findings indicate that injury from child maltreatment is a major cause of hospitalization of young children 5 years and younger and represents a significant cost to publicly financed health care. While hospital discharge data can be used for population-based surveillance of child maltreatment related trauma, there is need for improvement in the surveillance of these injuries.

Background: Acute intravascular hemolysis is rarely associated with platelet transfusion. Out-of-group single-donor platelets may cause hemolysis if the donor has high-titer ABO hemagglutinins., Case Report: A 44-year-old woman, blood group A, was recently diagnosed with acute myeloid leukemia and was receiving chemotherapy. After the transfusion of apheresis platelets from a group O donor, back pain, hemoglobinuria, and hemoglobinemia developed, and her Hb dropped by 2.3 g per dL, despite the transfusion of 2 units of RBCs., Results: Investigation revealed acute intravascular hemolysis with a positive DAT due to anti-A(1) on her RBCs. The donor's titer of anti-A(1) was greater than 16,000., Conclusion: Review of published cases raises the possibility that hemolytic reactions to out-of-group platelets may be more frequent since the use of apheresis platelets has increased.

A case of sclerosing epithelioid fibrosarcoma was studied. The tumor cells expressed vimentin, focally epithelial membrane antigen and CD34, contained cisternae of rough endoplasmic reticulum, large Golgi apparatus, many pinocytotic vesicles, and were devoid of basal lamina. Their composite karyotype was 45,Y,t(X;6)(q13;q15), t(6;13)(p11.2;q13),-22¿2/46,Y,t(X;6)(q13;q15),add(13)(p12), add(22)(q13)¿3/44 approximately 46,der(X)t(X;6)(q13;q21),-Y, t(13;14)(q10;q10),-22,add(22)(q13)¿7/46,XY¿8.

Bites by the Western diamondback rattlesnake (Crotalus atrox) are the most common cause of envenomation in Texas. We describe a patient who had delayed administration of antivenom after envenomation by C atrox. Because of an initial adverse response to a test dose, the patient had been unwilling to receive antivenom therapy. When compartment syndrome developed 52 hours after envenomation, however, the patient consented to antivenom therapy as an alternative to fasciotomy. We documented a decrease in compartment pressures and resolution of thrombocytopenia that was concomitant with antivenom administration.

Urinary thioethers are a biomarker for reactive metabolites, which are detoxified via glutathione. We conducted this study to establish the effect of diet on a sample of persons we screened to exclude exposure from such substances. Our second objective was to develop a distribution curve to be used for comparison to exposed populations. Volunteers were sought who did not work or live in locations where known toxic exposures were likely to occur. We mainly recruited office personnel and secretarial staff. We screened subjects for environmental exposures via a written questionnaire. Subjects gave us an initial random urine specimen before they were placed on a diet low in thioethers. We then measured urinary thioethers on these specimens with a modified Ellman technique. We compared 126 paired results. Results demonstrated that diet decreased urine thioether excretion in most cases (i.e., 75 of 126 had a decrease in thioethers). Initially, the difference in mean excretion at the time of prediet and postdiet, however, was not significant (p = .22). We removed 2 extreme outliers, the result of which was a significant difference in means (paired t test, p < .01). The standard deviation within each of the two groups did not differ significantly (p = .82).

A patient with newly diagnosed multiple myeloma manifested by urine kappa light-chain excretion and a small monoclonal spike (0.4 g/dl), presented with lower extremity deep venous thrombosis. A preheparin plasma-activated partial thromboplastin time (aPTT) was prolonged at 68 sec (normal control 26-42 sec). Additional studies confirmed the presence of lupus anticoagulant activity in the serum: the modified Russell Viper Venom Time (MRVVT) was 73 sec (normal control 24-42 sec) and with a 50:50 mix of the patient's plasma and pooled normal plasma, the MRVVT remained prolonged. Kappa light chains (LC) were isolated from the patient's urine and their purity confirmed by electrophoresis and immunofixation using specific immunoglobulin antisera. The patient's LC mixed with pooled normal plasma demonstrated LA activity by in vitro clotting tests (plasma-activated partial thromboplastin time 62 sec, with normal control of 45 sec), MRVVT of 44 sec with normal control of 35 sec. Purified urinary kappa light chains from a control patient with multiple myeloma and normal clotting studies, failed to prolong either the plasma-activated partial thromboplastin time or the MRVVT. We hypothesize that kappa LC in our patient demonstrated LA activity, which was unique to these LCs. Paraproteins with LA activity, to date, have included only intact immunoglobulins (Ig). While intact Ig paraproteins have been reported to possess LA activity, this is the first report to our knowledge of light-chain paraproteins possessing similar activity and resulting in clinically evident thrombosis. Light chain paraproteins could serve as useful models for further study of the mechanisms of activity of acquired LA inhibitors., (Copyright 1999 Wiley-Liss, Inc.)

The expression of surface antigen CD69 in immune response cells is typically associated with the early stage(s) of cell activation, with maximal expression levels within 4 h of appropriate antigenic or mitogenic stimulation, and maintenance of these high expression levels for 18-24 h. The expression profiles of CD69 in human peripheral blood mononuclear cells (PBMC) cultured with actinomycin D prior to mitogenic stimulation were evaluated by direct immunofluorescence using flow cytometry. Pretreatment of PBMC suspensions with low, non-toxic levels of actinomycin D stimulated CD3+ T-lymphocytes to express CD69 in a concentration-dependent manner. Furthermore, CD4+ T-lymphocytes were the primary cells responding in this fashion. Secondary mitogenic stimulation following antibiotic treatment potentiated cellular CD69 expression in these assays. CD69 expression was profoundly suppressed with in vitro actinomycin D concentrations >/=1-2 microg/ml, presumably by interference with cellular transcription/translation mechanisms. Parallel thymidine incorporation assays indicated that actinomycin D effectively inhibited thymidine uptake in a concentration-dependent manner, with complete inhibition at >/=0.1 microg/ml. The evaluation of cell cycling dynamics following antibiotic treatment, with and without secondary mitogen stimulation, indicated no substantial changes in DNA synthesis over controls. The diversity of these responses suggests that expression of CD69 may not solely reflect mitogenic activation status but may, under some conditions, result from induced cellular stress.

A 61-year-old man was admitted with acute posterior myocardial infarction and, on physical examination, was shown to have a mitral regurgitation (MR) murmur. Transthoracic echocardiography (TTE) showed severe hypokinesis of the posterior wall and severe MR by color flow. Right heart catheterization with a balloon-tipped catheter revealed a pulmonary artery wedge pressure of 30 mmHg. No 'step-up' was seen in blood samples from the right atrium and right ventricle. On angiography, a subtotal occlusion of the mid circumflex artery was found which was angioplastied and stented. As the patient's clinical condition did not improve, he underwent transesophageal echocardiography (TEE) for further evaluation. This showed complete rupture of the posteromedial papillary muscle. The patient underwent urgent surgery with successful mitral valve replacement. The postoperative course was uncomplicated, and clinical improvement seen. This case report underscores the value of TEE in accurate preoperative diagnosis of papillary muscle rupture by providing preoperative anatomic details of the mitral valve apparatus and surrounding structures.

Isoniazid-induced seizures respond poorly to anticonvulsants but well to pyridoxine (Vitamin B6); theophylline produces difficult-to-treat seizures with substantial morbidity and mortality. Theophylline therapy depresses plasma pyridoxal-5'-phosphate (PLP), the active metabolite of pyridoxine, suggesting that theophylline-induced seizures might be amenable to treatment with pyridoxine. Our study established the dose-response relationship for convulsions due to isoniazid and theophylline in mice and determined if pyridoxine antagonized such seizures. Female CD-1 outbred mice weighing 25 to 30 g were used. Clonic seizures had clonic activity lasting 5 sec; tonic seizures had loss of the righting reflex with tonic hindlimb extension. Groups of 10 mice received single doses of 50, 100, 150, 200, 250 or 300 mg aminophylline/kg i.p. or 100, 150, 200, 250, 300 or 350 mg isoniazid/kg i.p. and were observed for seizures or death. Pyridoxine or saline with aminophylline or isoniazid were administered simultaneously. The LD50 for aminophylline was 266 mg/kg; for isoniazid it was 160 mg/kg. Doses of 150 mg aminophylline/kg or 100 mg isoniazid/kg did not induce seizures. Pyridoxine with aminophylline or isoniazid did not alter the frequency or time of onset of seizures or death. This was unexpected because pyridoxine antagonizes theophylline-induced seizures in mice and reverses isoniazid-induced seizures in humans. We found no evidence that PLP depletion in mice is a mechanism for seizures induced by isoniazid or aminophylline in a fashion similar to isoniazid in humans.

Background: Pressure is increasingly being placed on medical sub-specialists to lower procedural costs while improving overall outcomes. Outcomes data reporting has been utilized in an attempt to improve procedural results; however, some negative aspects of this type of reporting have emerged., Methods: We surveyed 5,229 interventional cardiologists practicing in the United States regarding the effect of outcomes data reporting on their approach to high-risk patients who required interventional procedures. The results were analyzed one month after mailing the survey., Results: One thousand, four hundred and forty-four cardiologists responded to the survey. Ninety-three percent of the respondents indicated that outcomes data reporting would have some effect on their approach to high-risk patients. Only 7% said outcomes reporting would have no effect on their willingness to perform interventions on high-risk patients. The majority of respondents performed between 51 and 100 interventions per year; those who performed more than 500 interventions per year reported that they would be less affected if outcomes data were reported from their results., Conclusions: Our survey indicates that outcomes data reporting would have a significant effect on the willingness of cardiologists to perform procedures on high-risk patients; this effect may limit access to needed care for this high-risk population.

Clinically, the spread of infectious agents between subjects undergoing spirometry is quite uncommon. There is almost no documentation in the medical literature on this subject. We studied the retrieval of nonpathogenic Escherichia coli after aerosolizing organisms into standard pulmonary function tubing of a type that is frequently used by volume-sensing spirometers. The arrival of the aerosol at the distal end of the tubing was documented by culture. After delays of 0, 1, 5, and 10 min, respectively, air was forcibly withdrawn from the proximal end of the tubing through a special petri plate assembly. The plates were cultured and the colonies were counted. Immediately after insufflation of organisms, air withdrawn from the proximal tubing had counts similar to the air sampled at the distal end. After a 1-min delay, the proximal samples contained only rare organisms. No organisms were recovered from proximal air samples after a delay of 5 or 10 min after insufflation of organisms. The absence of detectable aerosolized E. coli after delays of 5 and 10 min after insufflation of organisms into spirometry tubing supports the hypothesis that a significant transfer of aerosolized organisms does not occur during routine pulmonary function testing as long as an interval of 5 min or more is allowed between tests.

The effects of local application of the endogenous brain neurotransmitter 5-hydroxytryptamine (5-HT; serotonin) into the dorsal (DR) or median (MR) raphe nuclei on haloperidol-induced catalepsy (CAT) in rats were studied. Local application of 5-HT (40 microg, -10 min) into the DR or MR, respectively, produced a significant reversal of haloperidol-induced CAT. Lower doses (5 or 25 microg) of 5-HT were ineffective. Compared to previous studies using the selective 5-HT1A receptor agonist 8-OH-DPAT, the non-selective endogenous serotonin receptor agonist 5-HT was significantly less potent in this paradigm. Furthermore, the observed anticataleptic effect of 5-HT was seen following injections into both DR or MR nuclei. The reversal of CAT by local application of 5-HT (40 microg) into the DR was significant also at 70 min after 5-HT administration, with the same tendency for 5-HT injections into the MR. At this time interval, other serotonergic behavioral symptoms like head twitches and wet-dog shakes also emerged. The early reversal of CAT by local 5-HT administration into the MR is in all probability mediated via stimulation of 5-HT1A autoreceptors on raphe serotonergic cell bodies. The reversal of CAT following 5-HT injections into the DR might alternatively be mediated via functional mechanisms other than stimulation of 5-HT1A autoreceptors. The anticataleptic effects observed at the later observation time could be due to stimulation of postsynaptic 5-HT2 receptors following diffusion of 5-HT into 5-HT2 receptor rich areas of the brain.

Purpose: To determine if measurement of lens protein in serum is a feasible means to gain information on the physiologic status of the lens in human subjects., Methods: The gamma-crystallin concentration was measured by a sandwich radioimmunoassay in the sera of 280 subjects aged 25-94 years. Medical records were reviewed for diagnoses of cataract and aphakia., Results: There was no effect of age or sex on the serum gamma-crystallin concentration. There were 57 subjects with cataract and 27 with aphakia. gamma-Crystallin was higher in all cataract groups and lower in aphakia. The mean gamma-crystallin concentrations for selected subject groups were as follows: clear lens 301 pg/ml; pure nuclear cataract 344 pg/ml; pure cortical cataract 439 pg/ml and aphakia 255 pg/ml., Conclusions: This is the first published report to show that lens protein is measurable in serum and to demonstrate the feasibility of using serum assays of lens proteins to gain information on the physiological status of the lens. Our results confirm the hypothesis that molecular and cellular events leading to cataract cause increased leakiness of lens cell membranes with release of lens proteins appearing in the blood. It is conceivable that measurement of lens proteins in serum might find future use in the evaluation of cataract risk, potentially cataractogenic and anticataractogenic agents, retained lens fragments after phacoemulsification, secondary cataract, phacolytic glaucoma, anaphylactic endophthalmitis, eye injuries, and other eye diseases.

Thirty patients had 32 cementless total hip arthroplasty revisions and were evaluated postoperatively for clinical function (Harris Hip Score) and radiographic evidence of implant stability. Of the 26 femoral components revised, 16 were revised with anatomic long-stem femoral prostheses, and 10 were revised with straight mid-stem-length components. All components were collared and had circumferential proximal fiber-mesh porous coating. Seven of 16 patients had radiographic subsidence after revision with long-stem components (2 to 30 mm); 6 of 10 patients had subsidence after revision with mid-stem femoral components (2 to 25 mm). Of the 13 patients with femoral subsidence, 8 had calcar reconstruction with allograft bone; of the 13 patients without radiographic subsidence, 8 did not require calcar reconstruction. One of 27 fiber-mesh, porous-coated acetabular components migrated (30 mm). No components have been removed or revised. Even with circumferential proximal porous coating, femoral implant stability remains unpredictable in total hip arthroplasty revision.

We developed methodology for prospective randomized effectiveness studies using a demonstration project at a multispecialty practice, health maintenance organization, and hospital in academic medical center. An operational unit called the effectiveness registry was developed to design and support comparisons of potential practice improvements with standard care. The studies differ from observational effectiveness studies in that they provide long-term follow-up of randomized comparison groups. Physician involvement in data collection is limited. No tests or observations are made other than those required for clinical care. Follow-up and data collection are modeled after tumor registry procedures. Patients who refuse randomization enter the study in whichever treatment arm they choose. The protocol for each study is approved by the institutional review board (IRB) before recruitment begins, and all patients, randomized and nonrandomized, sign an informed consent document. Between its beginning on October 7, 1993 and April 7, 1997, the IRB approved 14 trials. Four were terminated after entering at most a few patients. Recruitment is complete in four trials and continues in six. Randomization was accepted by 74% (596/804) of the patients. Over 800 patients in 10 studies are being followed at least annually. Major peer-reviewed journals have accepted reports of initial findings for two studies. Prospective randomized effectiveness studies are feasible in the multipractice setting and have potential to provide useful and reliable assessment of treatment outcomes. Collaborative arrangements between several institutions are needed to provide larger sample sizes.

Objective: This study was designed to determine the incidence of complications in a sample of 6,185 brachial artery punctures for arterial blood gas analysis., Methods: The study sample was comprised of adult patients who had arterial blood gas analysis ordered in the course of their clinical evaluations in a multispecialty clinic and hospital affiliated with a university school of medicine. Subjects were entered prospectively at the time the procedure was done., Results: The overall incidence of all complications was 2.0%. Immediate limb pain or parenthesias occurred in 1.1%, while the onset of symptoms was delayed up to 24 h in 0.9%. Hematoma formation occurred in only 0.06%. None of the complications was considered to be of major impact, in that none was associated with limb ischemia or other objective abnormalities. Only one subject required analgesic medication to control pain that ultimately subsided spontaneously without deficit., Conclusion: We believe that brachial artery puncture, when properly performed, is a safe and reliable alternative route for obtaining arterial blood for gas analysis.

Nipple-sparing total mastectomy remains an alternative for management of patients with high risk breast disease or patients with various types of symptomatic breast problems. In a patient with large breasts, however, achieving good cosmesis while still performing a thorough mastectomy remains a challenge. This report includes 10 patients who underwent unilateral nipple-sparing total mastectomy and 10 patients who underwent bilateral nipple-sparing total mastectomy. Tissue expansion was used as the reconstructive technique in this consecutive series done from 1985 through 1988. All expanders were placed in the submuscular position, and hyperbaric oxygen was used when intraoperative fluorescein administration identified marginally perfused areas. The average volume of breast tissue removed was 800 gm. The average permanent implant size was 767 cc. Complications included partial skin or nipple loss, infection, and problems related to the implants themselves. The complication rate, however, was not excessive, and results have been good as measured by cosmetic results, capsule grade, and lack of development of cancer in operated breasts. This reconstructive technique is recommended as an alternative in those patients undergoing nipple-sparing total mastectomy.

Described and evaluated here is a newly designed apparatus for the assessment of conditioned avoidance response (CAR) performance in rats. The system is computer-assisted using a design and system control development package based on the virtual instrument concept (LabView). The program, which allows for significant flexibility, greatly facilitated and simplified the process of timing and data acquisition. The apparatus was found effective and appropriately designed for CAR performance training, as well as for a reliable assessment of the effects of antipsychotic and potentially antipsychotic compounds on CAR in rats. The design presents a new, effective, and inexpensive option for laboratories involved in animal behavioral research.

We report catheterization laboratory personnel dose per case during parallel use of two laboratories from different manufacturers. Initially, four working positions were monitored. Review of the data from the first 140 cases showed a wide range of dose per case. Measurements were then limited to diagnostic coronary angiography cases in which a cardiology fellow was the primary operator. On a per case basis, the dose was higher when a fellow was in the laboratory with pulsed progressive fluoroscopy or was in fellowship year one. The increased dose for first year fellows was more related to increased fluoroscopy time than to cine angiography time. This study emphasizes the importance of close supervision of cardiology fellows early in their training to limit dose to patients and personnel, and it underlines the importance of each catheterization laboratory routinely having the actual personnel dose per case measured.

Troponin-T was measured in patients with chest pain and negative creatine phosphokinase-MB isoenzymes. Patients with elevated troponin-T had a significantly greater risk of cardiac events over the next 6 months than patients with normal troponin-T.

Determining the status of peripheral innervation can be difficult in certain patients. The phenomenon of skin wrinkling has been shown to be a reliable indicator of gross nerve function. This study examines the effect of various water temperatures on the time to skin wrinkling. The optimal temperature for testing hands is 40 degrees C and skin wrinkling should occur in approximately 3.5 minutes.

In examining the effects of corticosteroids on hematopoiesis in vitro, we observed that results were highly dependent on the lot of commercial fetal calf serum (FCS) utilized. We hypothesized that this variability correlated with the picogram (pg) level of endotoxin contaminating the FCS. Randomly obtained commercial lots of FCS contained 0.39 to 187 pg/ml of lipopolysaccharide (LPS). Standard FCS concentrations in hematopoietic precursor proliferation assays (granulocyte-marcrophage colony forming units [CFU-GM]) resulted in final LPS levels as high as 40 pg/ml. LPS (2-5 pg/ml) added to essentially endotoxin-free cultures, induced human mononuclear cell release of interleukin (IL)-1, IL-6 and granulocyte colony stimulating factor (G-CSF). Lots of FCS induced the release of IL-1, IL-6, and G-CSF from human mononuclear cells and the release of these factors correlated with the level of contaminating LPS. Human bone marrow CFU-GM proliferation, in response to granulocyte-macrophage colony stimulating factor (GM-CSF), positively correlated with the level of LPS contaminating the FCS and the FCS-induced release of IL-6 from mononuclear cells. CFU-GM proliferation of human bone marrow cluster of differentiation (CD) 34+CD14-cells were not affected by the presence of endotoxin. These data suggest that LPS at 2-5 pg/ml may induce bone marrow accessory cell release of hematopoietic growth factors, thus altering proliferative response of hematopoietic precursors and confounding the study of exogenously added cytokines to culture systems.

Patient-focused care is the redesign of patient care so that personnel and resources are organized around the patient instead of departments. The reasons are many but usually involve cost reductions and improvement in the customer's perception of quality. Goals for this process include grouping patients by diagnosis, decentralizing services, and cross-training staff. The respiratory care practitioner is well prepared to fit into the patient-focused care model. Recent surveys show the impact of hospital restructuring on respiratory care to be rather positive.

The Texas newborn screening for congenital hypothyroidism detects 90 to 150 cases each year; no affected babies have been missed. Babies dismissed from the hospital less than 24 hours after birth have a greater chance of an abnormal screening test, but most of the reported values reflect physiologic responses to birth and do not represent true hypothyroidism. A few represent thyroid disease. The astute physician recognizes a truly significant value; the unwary ignores a significant report and places the patient and himself at risk.

The authors present a follow-up of the Austin bunionectomy using a single 2.7-mm American Society of Internal Fixation (ASIF) screw. At a mean 5-year follow-up, 45 feet in 32 patients were evaluated with information from clinical examination, radiographic data, and responses to a patient questionnaire. When compared to the 18-month follow-up, good reduction of the intermetatarsal and the hallux abductus angle were maintained. Clinical findings, including the first metatarsophalangeal joint range of motion and hallux purchase power, remained acceptable, and a small number of new transfer lesions were noted. Patient satisfaction with appearance and overall satisfaction with the procedure remained excellent-to-good in 96% of the procedures.

Background: Erythema nodosum (EN) is a condition characterized by the presence of painful erythematous nodules on the pretibial aspects of the lower extremities. EN is thought to be a local inflammatory, immune-mediated reaction to a number of systemic antigenic stimuli. This condition is noted most often in women between menarche and menopause and is associated with certain drugs, infections, and pregnancy. However, no reports in the literature describe EN as a result of streptococcal infection during pregnancy., Case: A 21-year-old, white woman, G(3)P(0020), presented at 13 weeks gestation with a 2-week history of erythematous, tender lesions on the pretibial aspects of both legs consistent with EN. The patient reported having had a "flu-like" illness at the same time the lesions developed. The "flu" symptoms resolved within 10 days without medical intervention, but the lesions on her legs persisted. An initial antistreptolysin-O (ASO) titer was elevated at 960 Todd units (normal values: preschool and adults <85; school-age and young adults <170). Six days later, she presented to the emergency department with complaints consistent with a urinary-tract infection. She was empirically treated with a 10-day course of amoxicillin, 500 mg t.i.d. Although the patient was treated with amoxicillin for a presumed urinary-tract infection (which was culture-negative), the lesions resolved after her completion of the antibiotics. Twelve weeks later, a repeat ASO was within normal limits. The EN lesions did not recur., Conclusion: Although many etiologic factors are identified as causes of EN, the condition is usually self-limiting, requiring only minimal supportive measures until it resolves. A careful history should be obtained and a physical examination performed to exclude other causes. If a recent streptococcal infection is identified or presumed, a 10- to 14-day course of antibiotics is warranted.

An end-to-end anastomosis was done in the center of a 5-cm devascularized jejunal segment in 5 control laboratory rabbits and 14 experimental rabbits. A second group consisted of 5 control animals and 11 experimental animals having end-to-end jejunojejunostomy in the center of a 10-cm devascularized jejunal segment. In the experimental animals, the anastomosis was wrapped circumferentially by a vascularized omental pedicle. Anastomotic leaks or fistulas developed in five 10-cm controls (100%), five 5-cm controls (100%), nine 10-cm omental wraps (82%), and four 5-cm omental wraps (29%). The remaining animals had strictures of various degrees. Injection of methylene blue into the omental vessels showed perfusion to the mucosa from the omentum. The difference between the 10-cm segment and the 5-cm segment indicates some limitation to the available blood flow from the omentum. The anastomotic stricturing was due to ischemic injury before reperfusion by ingrowth of omental vessels. A vascularized omental pedicle wrap can augment blood flow; however, the time required for neovascular ingrowth allows ischemic mucosal injury if there is no other available blood supply.