Deconditioning fails to explain peripheral skeletal muscle alterations in men with chronic heart failure

It remains controversial whether the skeletal muscle alterations in chronic heart failure (CHF) are due to disease pathophysiology or result from chronic deconditioning. The purpose of this study was to compare the skeletal muscle of CHF patients to peak oxygen consumption (peak VO(2)) matched sedentary controls.It has been established that skeletal muscle abnormalities are related to the exercise intolerance observed in patients with CHF.We studied the skeletal muscle of sedentary controls and patients with CHF matched for age, gender and peak VO(2).Hypothesis testing for the effects of group (CHF vs. normal), gender, and the interaction group x gender were performed. For capillary density only gender (p = 0.002) and the interaction of group x gender (p = 0.007) were significantly different. For 3-hydroxyl coenzyme A (CoA) dehydrogenase only group effect (p = 0.004) was significantly different. Mean values for capillary density were 1.46 +/- 0.28 for CHF men versus 1.87 +/- 0.32 for sedentary control men, 1.40 +/- 0.32 for CHF women versus 1.15 +/- 0.35 for sedentary control women. The activities for 3-hydroxyl CoA dehydrogenase were 3.09 +/- 0.88 for CHF men versus 4.05 +/- 0.42 for sedentary control men, 2.93 +/- 0.72 for CHF women versus 3.51 +/- 0.78 for sedentary control women.This study suggests that women and men adapt to CHF differently: men develop peripheral skeletal muscle abnormalities that are not attributable to deconditioning; women do not develop the same pathologic responses in skeletal muscle when compared with normal women matched for aerobic capacity.     

Occlusion of a saphenous vein graft aneurysm with a vein-covered stent

A 67-year-old man was admitted with unstable angina, 15 years after saphenous vein graft bypass surgery. Cardiac catheterization demonstrated a large saccular aneurysm arising from the proximal segment of the vein graft to the obtuse marginal artery. Intravascular ultrasound revealed the opening of the aneurysm that measured 15 mm in length. The aneurysm was successfully occluded by deployment of a vein-covered stent.     

Intracisternal sodium nitroprusside fails to prevent vasospasm in nonhuman primates

OBJECTIVE: Hemoglobin contributes to vasospasm after subarachnoid hemorrhage. One mechanism may involve binding of nitric oxide, destruction of nitric oxide, or both. Support for this mechanism would be evidence that nitric oxide donors prevent vasospasm. This study attempted to provide such evidence. METHODS: A randomized, blinded study was conducted in which 13 monkeys underwent cerebral angiography and creation of a right subarachnoid hemorrhage. Subcutaneous osmotic pumps were implanted to deliver sodium nitroprusside (n = 7) or vehicle (n = 6) via catheters into the right basal cisterns. Seven days later, angiography was repeated, and the animals were humanely killed. Levels of cyclic nucleotides, hemoglobins, and thiocyanate were measured. RESULTS: Significant vasospasm of the right middle cerebral artery was present in animals treated with sodium nitroprusside (35 +/- 22% reduction in diameter, P < 0.05, paired t test) and placebo (28 +/- 20% reduction, P < 0.05, not significantly different from nitroprusside group by unpaired t test). Adequate delivery of sodium nitroprusside was supported by the finding of a significant increase in cyclic guanosine monophosphate levels in the cerebral arteries of treated animals compared with placebo (P < 0.05, unpaired t test). Thiocyanate was not present in significantly increased amounts in animals treated with nitroprusside, although this group did display elevated concentrations of nitrosyl hemoglobin (measured by electron paramagnetic resonance spectroscopy) and cyanomethemoglobin (measured by spectrophotometry) in the cerebrospinal fluid on Day 7. CONCLUSION: The lack of effect of sodium nitroprusside was not the result of inadequate drug delivery because cyclic guanosine monophosphate levels were significantly increased in vasospastic arteries. Vasospasm may not have been prevented because of a toxic effect of sodium nitroprusside metabolites, involvement of smooth muscle relaxation or contraction processes downstream of cyclic guanosine monophosphate, or both.     

Magnetic source imaging demonstrates altered cortical distribution of function in patients with arteriovenous malformations

OBJECTIVE: Arteriovenous malformations (AVMs) can be treated successfully, but treatment can pose unacceptable risks if the AVM is located in eloquent cortex. Because AVMs are developmental lesions, the location of primary cortical function may be deranged. We used magnetic source imaging (MSI) to identify the central sulcus and to determine whether primary cortical function was shifted in a set of 30 patients. We correlated these findings with outcome after treatment. METHODS: We retrospectively analyzed the clinical data of 30 patients with AVMs who underwent MSI. Nonparametric statistical comparisons were made to correlate the proximity of AVMs to primary cortex and somatosensory shift to outcome at 12 months. RESULTS: Using MSI, 14 patients (47%) were found to have AVMs involving primary cortex, and 10 patients (33%) were found to have shift in the somatosensory homunculus. Primary cortical involvement was neither required nor sufficient to cause shift (Mann-Whitney U test, z = -0.02, P = 0.31). Patients with AVMs involving primary cortex fared worse after treatment than did patients with AVMs that spared primary cortex (Mann-Whitney U test, z = -2.3, P = 0.02). The presence or absence of shift did not correlate with outcome after treatment (Mann-Whitney U test, z = -0.18, P = 0.48). CONCLUSION: MSI showed that some patients with AVMs have abnormal cortical distribution of function. The involvement of primary cortex correlated with worse outcome after treatment. Our results suggest that preoperative functional imaging may help to better estimate treatment risks and ultimately to guide therapeutic planning.     

Retrospective study of the management of chemotherapeutic extravasation injury

Despite the now widespread experience with the administration of chemotherapeutic agents in oncology, extravasation injuries still occur. Furthermore, the most appropriate management of such injuries is not known. The authors examined the current treatment options for extravasation injury and the incidence of this problem. All cases of extravasation referred to the plastic surgery service at one institution from 1994 through 1996 were examined. During a 6-year period there were 44 cases of extravasation injury identified in 42 patients. Comparison with a previous study conducted 15 years before at the same institution revealed a significant reduction in the incidence of extravasation injuries during that time (0.01% vs. 0.1%; = 0.00). The site of extravasation was peripheral in 32 cases and central in 12. Paclitaxel and doxorubicin were the two most common drugs involved. The local infusion of antidotes was not performed routinely. Only 26 of the 42 patients were referred to the plastic surgery service for care. Only 10 of those 26 patients required local ulcer excision and closure to achieve a healed wound. The mean time between injury and referral was 40 days. This time did not predict the subsequent need for a surgical procedure. Most patients, including the remaining 16 referred to the plastic surgery service, did not require surgical intervention. All were watched expectantly, and their injuries healed spontaneously. In conclusion, the incidence of extravasation is decreasing, most likely as a result of the diligence in the administration and identification of extravasation injuries as well as the result of the use of more central infusion sites. Most cases can be managed conservatively, with directed surgical treatment of the ulceration when appropriate.     

Chronic evaluation of the Cleveland Clinic CorAide left ventricular assist system in calves

The Cleveland Clinic CorAide left ventricular assist system is based on a third-generation, implantable, centrifugal pump in which a rotating assembly is suspended fully. To evaluate chronic in vivo system performance and biocompatibility, the CorAide blood pump was implanted in 18 calves for either 1 month or 3 months. Hemodynamics were stable in all calves with a mean pump flow of 5.9 +/- 1.2 L/min and a mean systemic arterial pressure of 98 +/- 5 mm Hg. There were no incidences of bleeding, organ dysfunction, or mechanical failure in any of the 18 calves. Hemolysis occurred in only 1 calf due to outflow graft stenosis. Thrombus inside the pump, seen in 4 of the first 6 cases, was totally eliminated by a final redesign in the remaining cases, including the last 6 implants conducted without anticoagulation therapy. The CorAide blood pump demonstrated good biocompatibility and reliable, effective system performance.     

Effect of Surgically-Induced Weight Loss on Leukocyte Indicators of Chronic Inflammation in Morbid Obesity

Background: Recent evidence suggests that morbid obesity is a chronic inflammatory condition that may be associated with immune dysfunction.To test this hypothesis, we investigated several leukocyte cell surface markers of chronic inflammation and followed their response to surgically-induced weight loss. Methods: 26 patients having Roux-en-Y gastric bypass (RYGBP) for morbid obesity (BMI>40) were compared to 10 normal controls (BMI<25). Relative monocyte and neutrophil frequencies and expression of the activation antigens CD11b (adhesion molecule), CD16 (Fc receptor), and CD62L (Lselectin), were evaluated by flow cytometry preoperatively and at 1, 3, 6 and 12 months after RYGBP. Cases served as their own controls but were also compared to non-obese controls. The results were statistically analyzed using Student's t-test and ANOVA for parametric values and Mann-Whitney along with Kruskal-Wallis ANOVA for nonparametric values Results: The control group had mean age 37 ± 7.6 with mean 23 ± 2.5 and no comorbidities. The mean age of the sample group was 40.36 ± 13.7 with mean BMI 52 ± 8.2. The neutrophil and monocyte relative frequencies of CD11b (monocytes and neutrophils), and CD16 (neutrophils only) were comparable to controls at baseline and did not change significantly with weight loss throughout the study period. However, a significant reduction of CD62L (Lselectin) expression was noted in monocytes and neutrophils at baseline (neutrophils 103 vs 240 gmf, p<0.001) (monocytes104 vs 246 gmf, P<0.001) when compared to normal controls. Levels of L-selectin normalized by 6 months in both monocytes and neutrophils, and by 12 months had become abnormally elevated in monocytes (monocytes 391 gmf, P=0.007); in neutrophils, there was an upward trend that did not reach significance.The expression of the LPS receptor CD14 in the study group was elevated significantly compared to controls at baseline (1129 vs 719 gmf, P=0.004); this marker appeared to return to normal by 3 months. Monocyte CD14+/CD16+ subset percentage were also elevated significantly at baseline (14.3% vs 5.25%, P <0.001), declined throughout the time period but was still significant at 1 year (8.8%, P<0.001). Eosinophil percentages were elevated at baseline (3.3% obese vs 1.8% controls, P=0.003) and remained so throughout the time period. Conclusion: Deficiencies in the immune system of morbidly obese individuals include elevated levels of eosinophils, monocyte CD14, and monocyte CD14+/CD16+ subsets, with depression of monocyte and neutrophil CD62L. These abnormal levels reverse rapidly with surgically-induced weight loss. RYGBP is not only a weight loss operation but also appears to be an immune restorative procedure.     

Isolated Horner syndrome and syrinx of the cervical spinal cord

PURPOSE: To alert ophthalmologists to the possibility of a spinal cord lesion in individuals with Horner syndrome and no neurologic symptoms. DESIGN: Observational case report. METHODS: Neuro-ophthalmic and neuroimaging assessment of a 16-year-old man with an isolated Horner syndrome localizing to a first- or second-order neuron. RESULTS: With magnetic resonance imaging, a syrinx of the cervical spinal cord extending from C5 to C7 was found. No Chiari malformation was present. CONCLUSION: Patients with an isolated Horner syndrome localizing to a first- or second-order sympathetic neuron should undergo magnetic resonance imaging of the head, neck, spinal cord, and chest to investigate for possible origins. An isolated Horner syndrome may be the presenting manifestation of a cervical syrinx.     

Cutting out the middleman: physicians can contract directly with employers--a viable alternative to adversarial managed care agreements

HMOs, PPOs, and other managed care "middlemen" control the means by which most physicians do business with employers. As physicians face dwindling reimbursements, greater practice restrictions, and increased pressure to sign adversarial middleman contracts, interest in direct contracting has grown. This article introduces direct contracting as an important alternative to commercial managed care agreements; cites the key advantages and process of direct contracting; and offers practical recommendations for helping physician practices successfully negotiate direct physician/employer agreements.     

Glaucoma patients' assessment of their visual function and quality of life

PURPOSE: To determine how glaucoma and glaucoma suspect patients' rating of their vision correlates with Esterman binocular visual field testing and other visual function tests. METHODS: One hundred ninety-one glaucoma patients and 46 glaucoma suspect patients underwent binocular visual field testing and evaluated their vision using the linear rating scale and time-tradeoff utility tests, the National Eye Institute Visual Functional Questionnaire (NEI VFQ-25), and the Short Form 36 (SF-36) quality-of-life instruments. RESULTS: The mean Esterman score was 88.2 +/- 17.4 for the glaucoma subjects and 95.2 + 6.9 for glaucoma suspect subjects (maximum score 100). On a scale from 0 (blind) to 100 (ideal), the mean rating of vision for glaucoma patients and glaucoma suspect patients was 74.8 +/- 17.3 and 78.9 +/- 18.5, respectively. The Esterman test correlated moderately with the overall NEI VFQ-25 score (partial correlation coefficient (PCC) = 0.32, P = 0.001), but only weakly with the linear rating scale (PCC = 0.17, P = 0.02), and the time-tradeoff (PCC = 0.14, P = 0.06). CONCLUSION: Utility values that glaucoma and glaucoma suspect patients assign to their vision do not correlate well with Esterman results. A challenge for the future is the design of clinical tests of vision that better correlate with patient perceptions.