Dynamic contrast-enhanced ultrasound with carbon dioxide microbubbles as adjunct to arteriography of liver tumors

Purpose The goal of the study is to evaluate utility of contrast enhanced ultrasound (US) with carbon dioxide microbubbles in evaluation of hepatic lesions.Methods Twenty eight patients with single or multiple t hepatic lesions (11 hepatocellular carcinoma, 8 hemangiomas, 5 metastases, 1 adenoma, 1 focal nodular hyperplasia, 2 regenerative nodules) were examined. US exam was performed during intraarterial injection of 10 ml of CO₂ through the same catheter employed for liver arteriography. The US exam was videotaped in its salient phases. Characteristics of enhancement were evaluated and correlated with histological findings or patient follow up.Results Sonographic angiography clearly demonstrated vascularization of the lesions. Hepatocellular carcinoma, hemangioma, metastases, focal nodular hyperplasia, and regenerative nodules had very characteristic patterns. The injection of CO₂ allowed detection of small additional nodules.Conclusion Sonographic angiography can improve characterization and staging of hepatic tumors. Low cost and the simplicity of the technique should encourage further experimentation.     

Nasal septal perforations: our surgical technique.

OBJECTIVE: The aim of this paper was to describe our surgical technique for the treatment of nasal septal perforations. STUDY AND DESIGN: We studied 31 patients with nasal septal perforation treated with an endoscope-assisted technique, based on a bilateral dissection of monopedicled mucosal flaps from the nasal fossa floor, sutured at the edge of the perforation previously unstuck, without any graft interposed between the two mucosal layers. RESULTS: In our experience with 31 patients, the use of this technique led to the persistent closing (with follow-up for at least one year) of 96.3% of the perforations smaller than 3 cm. CONCLUSIONS: Our technique has the advantage of an endonasal approach, without any external incision, and the use of monopedicled flaps from the nasal fossa floor without any graft interposition, avoiding any other surgical procedure and morbidity in the donor site of the graft. The use of nasal endoscopy permits superior precision in all surgical steps. SIGNIFICANCE: The high success rate in perforations smaller than 3 cm seems to confirm the effectiveness of this technique.     

TNF alpha and Fas mediate tissue damage and functional outcome after traumatic brain injury in mice.

Tumor necrosis factor-alpha (TNFalpha) and Fas are induced after traumatic brain injury (TBI); however, their functional roles are incompletely understood. Using controlled cortical impact (CCI) and mice deficient in TNFalpha, Fas, or both (TNFalpha/Fas-/-), we hypothesized that TNFalpha and Fas receptor mediate secondary TBI in a redundant manner. Compared with wild type (WT), TNFalpha/Fas-/- mice had improved motor performance from 1 to 4 days (P<0.05), improved spatial memory acquisition at 8 to 14 days (P<0.05), and decreased brain lesion size at 2 and 6 weeks after CCI (P<0.05). Protection in TNFalpha/Fas-/- mice from histopathological and motor deficits was reversed by reconstitution with recombinant TNFalpha before CCI, and TNFalpha-/- mice administered anti-Fas ligand antibodies had improved spatial memory acquisition versus similarly treated WT mice (P<0.05). Tumor necrosis factor-alpha/Fas-/- mice had decreased the numbers of cortical cells with plasmalemma damage at 6 h (P<0.05 versus WT), and reduced matrix metalloproteinase-9 activity in injured brain at 48 and 72 h after CCI. In immature mice subjected to CCI, genetic inhibition of TNFalpha and Fas conferred beneficial effects on histopathology and spatial memory acquisition in adulthood (both P<0.05 versus WT), suggesting that the beneficial effects of TNFalpha/Fas inhibition may be permanent. The data suggest that redundant signaling pathways initiated by TNFalpha and Fas play pivotal roles in the pathogenesis of TBI, and that biochemical mechanisms downstream of TNFalpha/Fas may be novel therapeutic targets to limit neurological sequelae in children and adults with severe TBI.     

The thermal effect on the blood flow response to electrical stimulation.

BACKGROUND: Wounds, especially in the elderly, can be life threatening. One modality which allegedly increases blood flow (BF) as an aid to heal chronic wounds is electrical stimulation. This technique applies electrical current (ES) across wounds. However, while many studies show positive findings, others do not. The purpose of this investigation was to investigate some of this inconsistency in results by determining the effect of environmental temperature on the circulation of the skin which may negate the effects of electrical stimulation in a clinical setting. MATERIAL/METHODS: Ten people with no wounds, controls (C), and 12 people with wounds (W) were examined in a thermally neutral or cool room (20 degrees C) and a warm room (34 degrees C) to observe the effect of reducing sympathetic vasoconstrictor activity on the response to 5 and 15 mA sine wave biphasic ES delivered by 2x2 cm surface electrodes. RESULTS: C and W subjects showed a greater BF in the skin in a warm room. In group C, after 30 minutes of stimulation at a current of 15 milliamps, BF increased significantly (p<0.05) but by an average of only 4 flux in the cool room. In the warm environment, BF increased significantly (p<0.01) by 19.3+/-7 flux and increased further during the 60 minute recovery phase. In the W group, BF during ES increased much more during stimulation in a warm room compared to a cool room. CONCLUSIONS: The results show that local vasoconstriction due to exposure to a warm global temperature greatly increases the response of the skin the ES.     

Nucleotide sequence of the leukotoxin genes of Pasteurella haemolytica A1.

A 4.4-kilobase-pair DNA fragment coding for the leukotoxin of Pasteurella haemolytica A1 has been isolated, and its nucleotide sequence has been determined. Two open reading frames, designated lktC and lktA, coding for proteins of 19.8 and 101.9 kilodaltons, respectively, were identified. Expression of the two genes in minicell-labeling experiments resulted in the production of the predicted proteins LKTC and LKTA. By using an antiserum against the soluble antigens of P. haemolytica A1 in Western blot (immunoblot) analysis of total cellular proteins from the Escherichia coli clones, LKTA was identified as an additional antigenic protein. Results from subcloning of the DNA fragment suggested that expression from both lktC and lktA is required for leukotoxin activity, indicating that the leukotoxin of P. haemolytica A1 is encoded by two genes. A comparison of the organization and the DNA sequence of the leukotoxin genes with those of the E. coli alpha-hemolysin genes showed a significant degree of homology between the two loci. This analysis suggested that the leukotoxin genes of P. haemolytica A1 and the E. coli alpha-hemolysin genes may have evolved from a common ancestor and that the two toxins may share similar activities or functional domains or both.     

Altered islet Beta-cell function before the onset of Type 1 (insulin-dependent) diabetes mellitus

Summary To define the glucose to insulin dose-response relationship before the onset of diabetes, we studied 22 nondiabetic co-twins of patients with Type 1 (insulin-dependent) diabetes mellitus and nine control subjects. All had intravenous glucose tests at 0.02, 0.1 and 0.5 g/kg and were followedup prospectively for at least 6 years. Seven twins developed diabetes a mean of 7 months later; the remaining 15 are now unlikely to develop diabetes. The seven pre-diabetic twins had higher fasting insulin levels than control subjects (4.2±2.0 vs 1.8±1.8 nmol/l; p<0.05); but lower glucose clearance (1.0±0.5 vs 1.9±0.7 %/min; p<0.05), first phase insulin response at 0.5 g/kg (21.1±23.2 vs 143±50 nmol/l; p<0.0001), and total insulin responses at 0.1 g/kg (p<0.05) and 0.5 g/kg (p<0.00005). Using a curve-fitting programme, the normal glucose to insulin relationship was lost in prediabetic twins who had lower coefficient of determination (R²) than control subjects (p<0.01). In contrast, 15 low-risk twins and their nine control subjects had similar fasting glucose and insulin levels, glucose clearance, R² and insulin secretory responses to different glucose loads. The positive predictive values of subnormal R² and subnormal first phase insulin response were 67 % and 58 % respectively. These observations demonstrate an altered glucose to insulin dose-response relationship and loss of maximum insulin secretory response to glucose before the onset of Type 1 diabetes.     

Adult-to-adult living donor liver transplantation using extended right lobe grafts.

OBJECTIVE: The authors report their experience with living donor liver transplantation (LDLT) using extended right lobe grafts for adult patients under high-urgency situations. SUMMARY BACKGROUND DATA: The efficacy of LDLT in the treatment of children has been established. The major limitation of adult-to-adult LDLT is the adequacy of the graft size. A left lobe graft from a relatively small volunteer donor will not meet the metabolic demand of a larger recipient. METHODS: From May 1996 to November 1996, seven LDLTs, using extended right lobe grafts, were performed under high-urgency situations. All recipients were in intensive care units before transplantation with five having acute renal failure, three on mechanical ventilation, and all with hepatic encephalopathy. The median body weight for the donors and recipients was 58 kg (range, 41-84 kg) and 65 kg (range, 53-90 kg), respectively. The body weights of four donors were less than those of the corresponding recipients, and the lowest donor-to-recipient body weight ratio was 0.62:1. The extended right lobe graft was chosen because the left lobe volume was <40% of the ideal liver mass of the recipient. RESULTS: Median blood loss for the donors was 900 mL (range, 700-1600 mL) and hospital stay was 19 days (range, 8-22 days). Homologous blood transfusion was not required. Two donors had complications (one incisional hernia and one bile duct stricture) requiring reoperation after discharge. All were well with normal liver function 5 to 10 months after surgery. The graft weight ranged from 490 g to 1140 g. All grafts showed immediate function with normalization of prothrombin time and recovery of conscious state of the recipients. There was no vascular complication, but six recipients required reoperation. One recipient died of systemic candidiasis 16 days after transplantation and 6 (86%) were alive with the original graft at a median follow-up of 6.5 months (range, 5-10 months). CONCLUSIONS: When performed by a team with experience in hepatectomy and transplantation, LDLT, using an extended right lobe graft, can achieve superior results. The technique extends the success of LDLT from pediatric recipients to adult recipients and opens a new donor pool for adults to receive a timely graft of adequate function.     

Discriminant analysis in diagnosing carcinoma of the pancreas and of the papilla of Vater

The clinical and biochemical presentation of carcinoma of the pancreas (PC) and of the papilla of Vater (CPV) are very similar, and, consequently, detailed investigations are required to correctly distinguish between them. The aim of the present study was to select the clinical and biochemical variables that would most efficiently discriminate the precise site of tumor origin. The study group consisted of 72 patients with PC and 22 patients with CPV consecutively hospitalized in our department. The following clinical parameters were considered: age, asthenia, anorexia, vomiting, weight loss, pain, fever, pruritis, and constipation; the biochemical parameters considered were total, direct, and indirect bilirubin, glucose, alkaline phosphatase, gamma glutamy transferase, transaminase, total protein, amylase, and occult blood in stools. The results indicated that in the initial phase of PC the most frequent clinical parameters were weight loss (P<0.0001), anorexia (P<0.02), constipation (P<0.001), and pruritus (P<0.01). In contrast, in CPV, fever (P<0.003) was most frequent in the same phase. There was a statistically significant difference in occult blood in stools (P<0.0001), total (P<0.03) and direct bilirubin (P<0.02), alkaline phosphatase (P<0.05), and transaminase (P<0.002) values in the two groups. On discriminant analysis, weight loss, constipation, pruritus, nausea, anorexia, and fever were the variables which best discriminated between the two types of tumors. In fact, the presence of weight loss, anorexia, asthenia, constipation, and pruritus correctly classified 87.5% of the patients with PC, while the presence of fever and nausea correctly classified 72.7% of the patients with CPV.     

Attitudes towards mental illness: testing the contact hypothesis among Chinese student nurses in Hong Kong

This study investigated whether previous contact with mental illness affected the attitudes to mental illness (AMI) of general student nurses in Hong Kong — the contact hypothesis. We employed a quasi-experimental design. We compared the attitudes to mental illness of students who had previous contact with mental illness through having taken a psychiatric secondment with those who had not taken a psychiatric secondment. Also, we compared the AMI of: students who had taken other courses related to mental illness with those who had not; those who had a family history of mental illness with those who had not; and those who lived with a mentally ill relative with those who did not. We found that previous contact with mental illness had no significant effect on the attitudes to mental illness of the students. In other words our findings do not support the contact hypothesis. Our sample expressed positive general attitudes to mental illness when presented with general issues about mental illness. However, their attitudes were less positive when presented with specific issues about mental illness that might impinge upon their daily lives. We discuss the implications of these findings for mental health nursing practice, education and research.