Carcinoma-associated dermatomyositis responding to plasmapheresis

We report a case of severe carcinoma-associated dermatomyositis which, having shown no response to conventional treatment, improved markedly within 48 h of plasmapheresis. We believe that this is the first time that dermatomyositis associated with an advanced carcinoma has been reported to respond in this way. Dermatomyositis can prove extremely difficult to treat and sometimes fails to respond even to very high doses of steroids and immunosuppressants. There is currently only a single report of the use of plasmapheresis in adult dermatomyositis. We therefore wish to support the findings of Dau and draw attention to the value of this therapeutic option in refractory dermatomyositis.     

Manifesto of space medicine: the next dermatologic frontier

As the fields of astronomy, cosmology, and space travel move rapidly forward, so must space medicine. The manned space program and medical knowledge and support have developed in tandem. Dermatology will play a fundamental role in survival during space flight. This paper reviews past, present, and future accomplishments of the space program as they relate to medicine and characterizes some of dermatology's multiple roles in the future. It further explores the immunologic alterations noted during space flight and the attendant implications for health and well-being both in flight and on return to Earth, or to an Earthlike environment.     

In situ hybridization analysis for herpes simplex virus nucleic acids in Alzheimer disease

Histological sections of brain from patients showing evidence of advanced pathology of Alzheimer disease (AD) were examined for the presence of herpes simplex type-1 (HSV-1) nucleic acids by a sensitive in-situ hybridization technique. Samples from neurologically normal patients were examined in parallel. Sensitivity of the assay was verified by the detection of HSV-1 nucleic acids in neurons of trigeminal ganglia taken from cases of AD and normal controls. This indicated that the hybridization reaction was sufficiently sensitive to detect latent HSV-1 infections. Positive hybridization in the brain was only detected in a confirmed case of herpes simplex virus encephalitis. These results appear to confirm previous reports that HSV-1 infection is not directly involved in the pathology associated with AD.     

Effect of membrane protectors on the diastolic function of the heart in patients with acute myocardial infarction

Apexcardiography was employed to make a noninvasive assessment of left ventricular diastolic function in 80 patients with extensive myocardial infarction. In half the patients, there were impairments in cardiac diastole as manifested by its altered phase structure and some changed parameters indirectly indicating a rise in left ventricular end diastolic pressure and a fall in myocardial relation rates and diastolic compliance. Prior 10-day administration of tocopherol and nicotinamide to 45 patients caused a decrease in the severity of diastolic abnormalities in those in whom the latter had been abnormal. The use of membrane protectors resulted in lower incidence of complications and improved outcome of the disease.     

The association of circulating endotoxin with the development of the adult respiratory distress syndrome

Despite extensive investigation, the pathogenesis of the adult respiratory distress syndrome (ARDS) remains uncertain. As yet, there is no clear explanation of why some patients at risk for ARDS develop the syndrome, whereas others do not. Neutrophils and complement fragments have been implicated in the acute lung injury, but it is clear from published data that evidence of complement activation alone predicts neither the development nor the severity of ARDS. We investigated whether the combination of endotoxin, a leukocyte-priming agent, and complement fragments, leukocyte-stimulating agents, was associated with the development of ARDS. Ninety-eight patients were identified as being either at risk for the development of ARDS or having ARDS, and serial blood samples were obtained. There was no correlation between C5 fragments and the development of ARDS. C3 fragment levels were increased in 89% of the patients with ARDS, but they were also increased in 62% of patients at risk. Endotoxin was detected in 74% of the plasma samples obtained from patients at risk who subsequent developed ARDS and in 64% of the plasma samples obtained from the patients with ARDS. In contrast, only 22% of the plasma samples obtained from the patients at risk who did not develop ARDS had measurable endotoxin. We suggest that the combination of endotoxin and complement fragments may be one mechanism involved in the development of ARDS.     

The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction

In 422 patients admitted from the emergency department (ED) for suspected acute myocardial infarction, the hypothesis that chest pain that persists on arrival in the ED or recurs during the initial ED evaluation is a useful predictor of acute myocardial infarction (AMI) and complications of coronary ischemia was tested. Compared with patients whose chest pain spontaneously ceased before arrival in the ED, patients whose chest pain persisted or recurred during the initial ED evaluation had a 2.3 times greater risk of interventions (P less than .001), a 1.7 times greater risk of complications (P = .045), a 3.8 times greater risk of life-threatening complications (P = .04), and a 2.4 times greater risk of AMI (P = .005). A third group of patients with suspected AMI never experienced chest pain. This group of patients who never experienced chest pain had a three times higher risk of death (P = .02) compared with patients whose chest pain persisted or recurred in the ED, and a 2.1 times greater risk of intervention (P = .01), a 5.2 times greater risk of life-threatening complication (P = .015), and a 7.9 times greater risk of death (P = .025) compared with patients whose chest pain resolved before arrival in the ED. It was concluded that patients with chest pain that resolves spontaneously before arrival to the ED have a better in-hospital prognosis than any other group.     

Beta-2 microglobulin and amyloid osteoarthropathy in patients undergoing chronic hemodialysis

The incidence of beta-2 microglobulin amyloidosis was assessed in two populations of chronic hemodialysis patients. Out of 34 patients who underwent biopsy during orthopedic surgery (33 cases) or autopsy (1 case), 26 had amyloid deposits which fixed anti-beta microglobulin serum. Out of 55 unselected patients treated for over months at the dialysis centre, 14 (25%) had clinical symptoms suggesting amyloidosis and out of 43 patients who had a systematic radiological skeletal survey, 23 (53%) had bone deposits. The plasma beta microglobulin concentrations (about 20 times the normal value) we not significantly different whether or not the patients had histological proven amyloidosis, clinically or radiologically probable amyloidosis, no detectable amyloidosis. However, the duration of hemodialysis was longer in those with proven or highly probable amyloidosis. The finding illustrate the indirect role of elevation of beta-2 microglobulin in the genesis of this pathology and also the necessity of lowering its concentration in order to avoid the long term complications of osteoarticular deposits, the functional consequences of which may be very serious.     

Bilateral rupture of diaphragm with delayed strangulation

A 64-year-old woman presented in shock. The computed tomography (CT) scan confirmed rupture of the left diaphragm with strangulation. Three days after surgery, the patient developed herniation of abdominal contents on the right side with cardiorespiratory collapse. Marlex mesh was used to repair on the right side. Postoperatively, she needed partial gastrectomy for massive duodenal ulcer bleeding. A dual chamber pacemaker was used to correct the complete heart block.