Elder abuse: is every bruise a sign of abuse?

Each year, between 1 and 2 million older adults in the United States are abused. Physicians are in an ideal position to recognize, manage and prevent elder mistreatment. This article uses a problem-solving format to discuss a case report. This case, which spanned two years, highlights the true difficulty in recognizing and managing elder mistreatment.     

Constrictive pericardial disease: prognostic significance of a nonvisualized left ventricular wall

Twenty-six patients with pericardial constriction confirmed by catheterization were studied by dynamic computed tomography (CT). The posterolateral wall of the left ventricular myocardium was not detected in five patients (19.2%). None had evidence of previous myocardial infarction on electrocardiogram or levocardiogram. In 16 patients, a pericardiectomy was performed to remove pericardial constriction. All five patients with nondetectable posterolateral walls of the left ventricle died at or immediately following surgery because of acute myocardial failure. Nonvisualization of the posterolateral wall of the left ventricle in patients with constrictive pericarditis suggests the presence of myocardial fibrosis or atrophy. Surgery is an extremely high risk in these patients.     

Gestational trophoblastic neoplasm of the uterus: MR assessment

Magnetic resonance (MR) imaging characteristics of uterine gestational trophoblastic neoplasia were prospectively studied in nine women (aged 21-58 years). MR imaging was done at the time of initial clinical diagnosis, after each of the first two cycles of chemotherapy, and 6-9 months after initiation of chemotherapy. Sagittal and transverse MR images of the pelvis were generated with a 0.35-T superconducting magnet and the double spin-echo technique with short and long repetition times (TRs). The neoplasm distorted the MR appearance of uterine zonal structures (myometrium, endometrium, and junctional zone) and demonstrated hypervascular masses of heterogeneous signal intensity. Favorable response to chemotherapy was determined by a decrease in serum beta-subunit human chorionic gonadotropin (HCG) concentrations, and was accompanied by MR findings of regression of vascular abnormalities, development of intralesional hemorrhage, and return of normal appearance of uterine zones. The return of uterine zonal anatomy on MR images antedated definitive decrease in uterine volume. All eight patients imaged 6-9 months after initial imaging showed normal uterine volume and zonal anatomy.     

Cognitive deficits associated with frontal-lobe infarction in children with sickle cell disease

This study examined the cognitive manifestations of frontal-lobe infarction in a population of children with sickle cell disease (SCD). Forty-one patients with SCD underwent MRI. Five patients with stroke symptoms had large infarcts encroaching on the tissue of the frontal lobes. Four patients without symptoms had smaller frontal-lobe infarcts. The patients with stroke were significantly impaired on measures of intelligence, memory, and frontal-lobe function (Wisconsin Card Sorting Test, WCST) compared with both the patients with normal MRI scans ( N = 30) and a group of sibling controls ( N = 15), who did not differ from each other. Patients with covert infarction obtained scores on the intelligence tests and the WCST that fell in between those of the stroke patients and the other two groups. This trend toward impairment suggests that patients with covert infarction are at similar risk for cognitive deficits to those with stroke.     

Antibody response in an ABO-incompatible blood transfusion. Antigen specificity and immunoglobulin class

The anti-A response in a group B patient accidentally given 1 unit transfusion of A1 blood is described. The antibody response is characterized both with conventional agglutination techniques and with radioimmunoassay using pure group A antigens with different core saccharide structures (type 1, 2, and 4 chains) and class-specific second antibodies. The anti-A titer rose to a maximum Days 11 to 14 after the incompatible transfusion. The antibodies involved were mainly of the IgG and IgA types, while the IgM response was moderate. The IgA antibodies seemed to be nonselective with respect to group A antigen type, while the IgG antibodies showed a specificity against type 2 chain group A antigens.     

Sickle reticulocytes adhere to VCAM-1

Adherence of sickle (SS) erythrocytes to endothelial cells represents interactions between red blood cell (RBC) and endothelial cell surface molecules. To enhance our understanding of the ligands involved, we transfected COS cells with the cDNAs of two endothelial cell adhesion molecules, VCAM-1 and E-selectin, and measured the binding of normal and sickle RBCs after static incubation. The percentage of COS cells with rosettes (five or more adherent RBCs) was determined. Normal RBCs did not adhere to VCAM-1-transfected COS cells. Unfractionated SS RBCs formed rosettes on the VCAM-1-transfected COS cells (mean +/- SD, 5.85% +/- 4.98%). Low-density SS RBCs were more adherent than high-density SS RBCs (P < .005). The adherent SS RBCs were a young reticulocyte population, staining positively for transferrin receptor. Another measure of reticulocyte age, RNA content, also correlated with adherence. SS RBC binding was specific--inhibitable by antibodies to either VCAM-1 or the alpha 4 integrin chain of VLA-4. In contrast, there was no significant adherence of normal or SS RBCs to E-selectin- transfected COS cells. These results suggest that young reticulocytes bind to endothelial cell VCAM-1 via VLA-4 integrin.