Transluminal laser catheter angioplasty

The first transluminal laser angioplasty in animals is reported herein. An Argon laser and a specialized coronary arterial catheter with a fiberoptic wave guide were used. Immediate histologic changes consisted of a moderate degree of intimai necrosis and some loss of elastic tissue. At 5 days the intima was repaired, but focal elastic tissue loss persisted.     

Acute pulmonary edema due to ischemic heart disease without accompanying myocardial infarction: Natural history and clinical profile

The natural history of acute cardiogenic pulmonary edema was studied in a group of patients who did not have acute myocardial infarction, cardiomyopathy, or valvular heart disease. Most of these patients had coronary artery disease. Cardiac catheterization in selected patients showed depressed contractility in some with segmental abnormalities. In the group older than 70 years, this carried a 70 percent two-year mortality rate. It is important to approach patients with this syndrome vigorously, both diagnostically and therapeutically. Acute, reversible segmental ischemia may be responsible for this syndrome and may respond to measures designed to prevent recurrent ischemia.     

A new observation in the clinical spectrums of erythroleukemia. A report of 46 cases.

Erythroleukemia is a disease manifested by an abnormal proliferation of erythroid and myeloid precursors, generally consisting of a primary erythroid phase (chronic erythemic myelosis), a transition phase involving erythroid and myeloid precursors (erythroleukemia) and, finally, the purely myeloblastic (acute myeloblastic leukemia) phase. The experience at Memorial Sloan-Kettering Cancer Center is reported. Presenting signs and symptoms are consistent with prior reports. The chemotherapy results in the past have been poor; because of the poor results, chemotherapy is started only if one of the following criteria are present: (1) frequent transfusion requirements; (2) rapidly increasing peripheral white blood cell count or percentage of leukemic blast forms; (3) frequent recurrent infectious and/or hemorrhagic complications. A hitherto unrecognized association of erythroleukemia and symptomatic rheumatic disease and numerous immunologic abberations are reported. The symptoms related to this rheumatic disorder do not seem to be relieved by therapy directed at the leukemic process, but rather by the use of simple anti-inflammatory agents.     

Bacterial invasion of pulmonary vessels: Pseudomonas bacteremia mimicking pulmonary thromboembolism with infarction

Pseudomonas aeruginosa displays a curious propensity for invading blood vessels and causing vessel wall necrosis. This bacteremiarelated “vasculitis” is often associated with hemorrhagic necrosis and infarction of surrounding organ parenchyma. With the exception of skin lesions, however, clinical manifestations of Ps. aeruginosa vasculitis seldom occur. In the patient we describe, fatal Ps. aeruginosa bacteremia was first manifested by a syndrome indistinguishable from pulmonary thromboembolism with infarction.     

Legionnaires' disease. A cause of severe abscess-forming pneumonia.

In two previously well nonsmokers fatal pneumonia developed with extensive abscess formation. Legionnaires' bacillus was the only pathogen isolated. These cases indicate that Legionnaires' bacillus is capable of causing extensive necrosis of the lung.     

Hyperimmunoglobulinemia associated with narcotic addiction. Effects of methadone maintenance treatment

Increased serum immunoglobulins were common in narcotic addicts. Immunoglobulin M (IgM) levels were high in 75 per cent of 46 adult addicts and in 65 per cent of 63 adolescent addicts seeking methadone maintenance or detoxification. Isolated hypermacroglobulinemia was found in 56 per cent. During methadone maintenance or abstinence high IgM levels were much less frequent. History of overt hepatitis, manifest liver disease, serum glutamic oxaloacetic transaminase (SGOT) or alkaline phosphatase levels did not correlate with the presence of high serum IgM levels. Serum immunoglobulin G (IgG) was more variably and less frequently increased than IgM in the untreated addicts, but was commonly increased in the patients maintained on methadone. Prospective studies of 21 patients starting methadone maintenance showed a decrease in mean serum IgM during treatment. The incidence of normal IgM levels in these patients rose to 48 per cent after one year compared to 24 per cent before treatment. The pattern of immunoglobulin changes in narcotic addiction is significantly altered during methadone maintenance treatment, perhaps as a result in the reduction of drug abuse.     

Extreme hypocapnia in the critically ill patient

Respiratory alkalosis was the most common acid-base disturbance observed in a computer analysis of 8,607 consecutive arterial blood gas studies collected over an 18 month period in a large intensive care unit.Through a retrospective review of the randomly selected hospital records of 114 patients, we defined four groups based upon arterial carbon dioxide tension (PaCO₂) and mode of ventilation. Group 1, with a PaCO₂ of 15 mm Hg or less, consisted of 25 patients with an over-all mortality of 88 per cent. Group II, with a PaCO₂ of 20 to 25 mm Hg, consisted of 35 patients with a mortality of 77 per cent. Group III, with a PaCO₂ of 25 to 30 mm Hg, consisted of 33 patients with a mortality of 73 per cent, and Group IV, with a PaCO₂ of 35 to 45 mm Hg, consisted of 21 patients with a mortality of 29 per cent (p <0.001). Shock and sepsis were most common in group I patients.These findings suggest that extreme hypocapnia in the critically ill patient has serious prognostic implications and is indicative of the severity of the underlying disease.     

Aspergillosis complicating neoplastic disease

From 1964 to June 1971, 93 cases of aspergillosis were encountered at Memorial Sloan-Kettering Cancer Center. The 29 cases diagnosed in 1969–1970 and the 15 cases diagnosed in the first half of 1971 represented, respectively, a doubling and a quadrupling since 1964–1965. The incidence of aspergillosis in patients with leukemia was seven times greater than in patients with Hodgkin's disease or lymphoma (p < 0.0005). By the first half of 1971, 41 per cent of the patients who died with acute leukemia had evidence of aspergillosis. Fourteen patients with solid tumors resembled patients with leukemia or lymphoma in that they had at least two of the following in common: corticosteroid treatment, cytotoxic therapy and leukopenia (less than 4,000 cells/mm³). Pulmonary involvement was present in 90 of 93 cases, disseminated disease in 23. The commonest clinical pattern was unremitting fever and development of pulmonary infiltrates despite broad-spectrurh antibiotic therapy. In an increasing number of cases aspergillosis followed Pseudomonas aeruginosa infections. When present, serum aspergillus precipitins correlated well with invasive disease, but a negative test result was far less reliable. In one case of acute myelogenous leukemia the patient recovered from pulmonary aspergillosis after surgical excision of the lesion and remission of her leukemia.The incidence of aspergillosis is increasing and should be considered in the setting of progressive pulmonary infiltrates in leukemic and other heavily immunosuppressed patients who respond poorly to antibacterial therapy. Earlier diagnosis may lead to more effective therapy.     

Oral trimethoprim/sulfamethoxazole in attempt to prevent infection after induction chemotherapy for acute leukemia

The efficacy of orally administered trimethoprim/sulfamethoxazole for infection prevention following induction chemotherapy was evaluated in 43 patients with acute leukemia. Twenty patients were randomly assigned to treatment with trimethoprim/sulfamethoxazole during 20 episodes of profound granulocytopenia; 23 patients in the control group were followed through 25 granulocytopenic episodes. The incidences of superficial skin and overall infections were significantly lower in those patients with multiple relapses who received trimethoprim/sulfamethoxazole (p = 0.008); however, there was no difference between the groups in regard to days of fever, days of antibiotic administration, days of hospitalization, or gram-negative rod bacteremia. As a result of this study, this regimen cannot be unequivocally recommended for infection prevention in neutropenic patients with acute leukemia undergoing induction or reinduction chemotherapy.     

Late systolic murmur of rheumatic mitral insufficiency

Of 184 patients with acute rheumatic fever and associated mitral insufficiency encountered during a 15 year period, 34 manifested a mid-late systolic murmur or a nonejection click, or both, during the course of follow-up.The mid-late systolic murmur later disappeared in four patients whose condition is now considered normal. In one of the four, systolic prolapse of the mitral valve was demonstrated on an angiocardiogram obtained when the systolic murmur was present. Since disappearance of the murmur there has been no evidence of systolic prolapse on meticulous echocardiographic study of the mitral valve. In another child with angiographically demonstrated systolic prolapse of the mitral valve the systolic murmur has also disappeared, but systolic prolapse is still evident on echocardiographic study.None of the 34 patients with a mid-late systolic murmur manifested the T wave abnormalities commonly associated with the familial variety of mitral valve prolapse.     

Persistent viral hepatitis

The discovery of the HB antigen has resulted in a relatively simple way to detect the HB virus. This has allowed not only the separate nature of the two main forms of acute viral hepatitis to be confirmed, but has also allowed an assessment of the role of the HB virus in chronic liver disease. Investigations on the latter have indicated that the HB virus may be responsible for a very significant proportion of cases of serious chronic liver disease. As yet it is not known how the HB virus causes acute or chronic liver damage, although immunologic mechanisms are suggested. The HB virus can spread by other than parenteral routes, and investigations for the HB antigen indicate that spread by at least the saliva and across the placenta may be among these. Insect vectors may be important in certain areas.     

Abdominal pain associated with IgA nephropathy. Possible mechanism

A 36-year-old man presented with IgA nephropathy (Berger's disease) and acute abdominal pain. Surgical biopsy of the ileum revealed deposits of IgA, C3, and fibrin in segments of the wall of submucosal arteries. The immune deposits appeared associated with areas of fibrinoid necrosis. These findings support the hypothesis that Berger's disease is a systemic disease, and provide a possible explanation for the abdominal pain associated with IgA nephropathy.     

Secondary gout associated with chronic myeloproliferative disorders.

The early recognition of acute gouty arthritis, prompt institution of colchicine and/or other antigouty inflammatory drugs, and the use of colchicine prophylactically during the interval periods are necessary measures for the control of secondary gout. The importance of administering allopurinol to prevent the extreme hyperuricemia and excessive hyperuricosuria in blood dyscrasias even before the onset of gouty arthritis should not be overlooked. However, the dosage of allopurinol must be titrated according to the degree of the hyperuricemia and of hyperuricosuria. The control of excessive hyperuricemia in patients receiving chemotherapy is particularly important. The side effects including its impact on the liver and the hemopoietic system should be kept in mind. It must also be remembered that the therapy may change the clinical course of secondary gout, but the course of the underlying blood dyscrasias may not be altered.     

Central nervous system involvement at presentation in acute granulocytic leukemia: A prospective cytocentrifuge study

We have undertaken a perspective study of the prevelance of the central nervous disease in acute granulocytic leukemia (AGL). Thirty-nine newly diagnosed patients with AGL underwent cytocentrifuge examination of cerebral spinal fluid. Seven of the 39 patients had blast cells in their cerebral spinal fluid. All seven of these patients had acute myelomonocytic leukemia (AMML). No patients with other variants of AGL demonstrated blast cells in their cerebral spinal fluid.Other high risk factors associated with meningeal infiltration were elevated serum lysozyme levels, high peripheral white blood cell count, low age, splemomegaly and the presence of infiltration in other organs.The admission rates for patients with meningeal leukemia were lower and the survival time was shorter than in both the 32 noninvolved patients and the noninvolved patients with AMML. We believe that a lumbar puncture is indicated in all patients with newly diagnosed AMML.     

Some unusual features of gouty arthritis in females

Gouty arthritis in females is relatively infrequent, although the sex ratio may be somewhat altered in different races. A positive family history is relatively prevalent among females whose onset of gout is premenopausal. In those patients with a postmenopausal onset, the incidence of diuretic-associated gout is high. The bimodal distribution of serum urate might be related to some variance of genetic transmission in female gout.Hypertension and coronary heart disease are common coexisting conditions, as is true of gouty arthritis in males. Chronic urinary tract infection dating from previous pregnancies is a frequent complication. The relative prevalence of proteinuria and diminished renal function leads to increased hyperuricemia, with a tendency to a low urinary uric acid output. This explains in part the higher incidence of extensive tophaceous deposition but lower incidence of renal calculi. Diuretics are associated with a higher urine pH, likewise, they reduce the urinary uric acid excretion. This also may contribute to the lower incidence of renal calculi.There may be some statistical support for the low fertility rate among the gouty females. Only two females became pregnant after the onset of gouty arthritis. All other pregnancies occurred before the onset of arthritis. Even then, abnormal pregnancies were relatively frequent. Some hormonal malfunction among the gouty females cannot be discounted.Both renal calculi and tophi are frequent in female gout associated with blood dyscrasias. They may manifest early, preceding the first attack of acute gouty arthritis. In both the male and female secondary gout, the primary underlying disease governs the uric acid metabolism and the clinical symptomatology of gout. The predominant role in pathogenesis is the excessive rate of uric acid production, and its disposal is governed by the different stages of the underlying disease and the treatment. Thus, secondary gout in females appears to be somewhat different from primary gout in females, but not different from secondary gout in males.     

Infection and diabetes: The case for glucose control

This review summarizes data concerning the host resistance to infection in diabetes and the influence of an acute infection upon the endocrinologic-metabolic status of the diabetic patient. While it is well known that acute infections lead to difficulty in controlling blood sugar levels and that infection is the most frequently documented cause of ketoacidosis, controversy persists as to whether or not patients with diabetes mellitus are more susceptible to infection than age- and sex-matched nondiabetlc control subjects. Our data obtained from the charts of 241 diabetic patients who were being followed as outpatients show a striking direct correlation between the overall prevalence of infection (p < 0.001) and the mean plasma glucose levels (representing three or more fasting glucose determinations taken at times when no evidence of infection existed). There is a significant diminution in intracellular bactericidal activity of leukocytes with Staphylococcus aureus and Escherichia coli in subjects with poorly controlled diabetes in comparison with the control group. Serum opsonic activity for both Staph. aureus and E. coli were significantly lower than in the control subjects. Taken together, the results from published reports as well as our data suggest to us that good control of blood sugar in diabetic patients is a desirable goal in the prevention of certain infections (Candida vaginitis, for example) and to ensure maintenance of normal host defense mechanisms that determine resistance and response to infection.     

Serologic evidence of toxoplasmosis among patients with polymyositis

The prevalence and quantity of anti-Toxoplasma antibodies were greater in a group of 10 patients with polymyositis than in patients with other inflammatory muscle diseases or other diseases. Eight of these patients with polymyositis had positive Sabin-Feldman tests. Complement-fixing antibodies, usually associated with recent infection, were present in five of them. These patients had no other findings suggestive of acute toxoplasmosis except for myocarditis, which occurred in one. The prevalence of positive serologic findings was not related to age, birthplace or steroid therapy. Most positive results in patients with polymyositis occurred in those who had had the disease for 1 year or less. Sequential antibody titers were obtained in four patients with polymyositis. All had unusually elevated antibody titers early in the disease with a fall in titers after several months. Attempts at isolation of T. gondii from three of these patients failed. Three patients were treated with pyrimethamine and sulfonamides; one died within weeks and the other two showed gradual improvement within months.     

Acute renal failure in patients with multiple myeloma

In the past, patients with multiple myeloma and acute renal failure have had a poor prognosis. Few patients recovered renal function and fewer still survived for prolonged time periods. This report describes the course of 10 patients with multiple myeloma and true acute renal failure treated during the decade 1970 to 1980, and reviews recent reports concerning this association. The use of radiographic contrast agents is no longer the primary predisposing factor to acute renal failure in the myeloma population. Rather, infection, hypercalcemia, and dehydration in the presence of light chain excretion are the major conditions precipitating the renal failure. Despite severe renal failure requiring dialysis, many patients may regain good renal function. Factors associated with a good or poor prognosis in this population are reviewed. The prognosis in patients with myeloma and acute renal failure has greatly improved in recent years, and prolonged survival may occur.     

Bacteroides fragilis resistant to the administration of clindamycin.

The susceptibility of Bacteroides fragilis to the administration of clindamycin, and the efficacy of this agent in Bacteroides infections are well documented. Clindamycin-resistant strains of B. fragilis were isolated from two patients with bacteremia at two institutions. Clinically significant resistance to clindamycin therapy has not been noted previously in B. fragilis infections.     

Accidental hypothermia in an alcoholic population

Thirty-nine cases of accidental hypothermia are reviewed. Data indicate that mortality varies with the presence of underlying disease rather than with the degree of hypothermia or the methods of rewarming. In 31 patients with hypothermia alone (average temperature 85 °F) mortality was 6.25 per cent. In eight patients with hypothermia and another primary condition (average temperature 84 °F) mortality was 75 per cent.Intractable cardiac arrhythmia has been reported as the primary cause of death in hypothermia. In these patients, death during hypothermia resulted from pulmonary complications. Ventricular arrhythmias, when they occurred, were responsive to routine measures such as electrical cardioversion and myocardial suppressant drugs. Methods of treatment are discussed.