Repeat thymectomy in chronic refractory myasthenia gravis

Encouraged by recent results with "extended" thymectomy in the treatment of myasthenia gravis, we carried out repeat thymectomy in six patients with chronic, refractory disease who did not initially have extended thymectomy. All were completely disabled with longstanding myasthenia. Initial thymectomy (four transsternal, one transcervical, and one substernal) was carried out at a mean of 8.9 years previously (range, 5 to 18). There was no residual thymus observed with CT, but at repeat thymectomy, residual thymic tissue was present in five of six patients. Five patients significantly improved and four returned to full-time work. Mean prednisone dose declined from 51 mg to 18 mg/d, and mean pyridostigmine dose fell from 1,290 mg to 415 mg/d. No patient to date has had a complete remission. These results suggest that repeat thymectomy may benefit some patients with chronic disabling myasthenia gravis, especially when it is uncertain from a review of the operative report whether all thymic tissue was removed at the initial thymectomy.     

Norepinephrine depletion impairs motor recovery following sensorimotor cortex injury in the rat

Beam-walking in the rat provides a method for investigating the effects of drugs on motor recovery following unilateral injury to the sensorimotor cortex. In the present experiment, the impact of norepinephrine depletion on beam-walking recovery was investigated. Groups of rats were first given either the neurotoxin DSP-4 or saline. Two weeks later, the animals were trained at the beam-walking task. Rats were then subjected to either a unilateral sensorimotor cortex lesion or sham operation. Recovery of beam-walking performance was measured over the next 12 days. Pretreatment with DSP-4 significantly slowed the rate of recovery but did not significantly affect sham-operated rats. Norepinephrine was significantly diminished in both lesioned and sham-operated rats that had been given DSP-4. These results are consistent with the hypothesis that recovery of beam-walking in the rat is mediated, at least in part, through noradrenergic neurons.     

Improvement of spectral resolution in shift-reagent-aided 23Na NMR spectroscopy in the isolated perfused rat heart system.

The level of intracellular sodium (Nai) is maintained at approximately 14 mM in healthy myocytes. When myocytes are damaged, Nai increases and therefore the level of Nai may be a means of evaluating myocardial cell integrity. A particularly useful method to monitor Nai levels is 23Na NMR spectroscopy. However, because of the isochronous nature of the extracellular sodium (Nao) and Nai NMR signals, paramagnetic lanthanide shift reagents (LSR), such as dysprosium triphosphate, Dy(PPP)7-(2), have been used to shift the Nao signal. This reveals the unshifted Nai signal and allows the NMR monitoring of Nai in isolated perfused hearts and other systems. A major shortcoming of this method (the "shift-only" method) is in the need to minimize the Nao signal by not submerging the perfused hearts in Na(+)-containing buffer. An equally undesirable alternative is the utilization of relatively high concentrations of LSR to shift a large Nao signal sufficiently to enable reasonable resolution and quantitation of Nai. We present here a method, the "shift-relaxation" method, which is a combination of using a mixture of Dy(PPP)7-(2), a shift reagent, and gadolinium triphosphate, Gd(PPP)7-(2), a relaxation agent, with data acquisition using an inversion-recovery (IR) pulse sequence. This combination allows differentiation between Nao and Nai by the difference in their respective T1 values in addition to the shift between them. With this technique we can selectively minimize the extracellular signal and therefore minimize the need for a large Dy-induced shift, as well as allow data acquisition on a heart submerged in Na(+)-containing perfusate. The resulting improved discrimination between Nai and Nao at relatively low levels of LSR should be helpful for ultimate in vivo applications and potential clinical applications, where a lower dose of LSR also means a decreased possibility of physiologically deleterious effects. Also included in this paper is a method for the quick determination of an accurate 180 degrees pulse which is required for the optimization of the IR method.     

Long-term outcome following anterior cerebral artery ligation for ruptured anterior communicating artery aneurysms

The long-term prognosis (15 years) was determined for 17 patients who had undergone anterior cerebral artery (ACA) ligation as the sole treatment for an anterior communicating artery aneurysm. The number of early and late rebleeds was lower than expected from previously ruptured aneurysms. Late ischemia was not a major complication while late postoperative epilepsy occurred in 19% of survivors. In a review of previously published series, ACA ligation appears to have significantly reduced the rates of both early and late rebleeding. This study helps to define the late results of "conservative" operations for ruptured aneurysms.     

Severely injured geriatric patients return to independent living: a study of factors influencing function and independence

Our previous work demonstrated that geriatric trauma patients (age greater than 65 years) consume disproportionate amounts of health care resources. In the past we hypothesized that late mortality is high, long-term outcome is poor, and return to independence is low in a severely injured geriatric population. Of 6,480 trauma admissions over 5 years, geriatric patients (n = 495) with blunt trauma injury (n = 421) and an ISS greater than 16 (n = 105) who survived until discharge (n = 61) underwent long-term follow-up (mean = 2.82 years). We surveyed 20 measures of functional ability; 10 measures of independence; availability and use of rehabilitation resources; employment history; alcohol use; support systems; and nursing home requirements. Of the 105 patients, 7 were subsequently lost to follow-up. Among the remaining 98, 44 (44.9%) died in hospital and 54 (55.1%) were discharged and interviewed. The mean age of the contacted patients was 72.6; their mean ISS was 23.3. Forty eight of 54 (88.9%) were alive at the time of interview, while 6/54 (11.1%) had died. Although only 8/48 patients regained their preinjury level of function, 32/48 (67%) returned to independent living. The 32 independent patients, those with "acceptable" outcome, were compared with an "unacceptable" outcome group composed of the 44 in-hospital deaths, the 6 late deaths, and the 16 dependent patients. Factors associated with poor outcome include a GCS score less than or equal to (p = 0.001), age greater than or equal to 75 (p = 0.004), shock upon admission (p = 0.014), presence of head injury (p = 0.03), and sepsis (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

The Situation Analysis Study of the family planning program in Kenya

A new, relatively "quick and clean" operations research approach called a "situation analysis" was developed for examining the strengths and weaknesses of the family planning program of Kenya. Field research teams visited a stratified random sample of 99 of the Ministry of Health's approximately 775 service delivery points. Observation techniques and interviewing were used to collect information on program components and on the quality of care provided to new family planning clients during the observation day. As late as 1986, the Kenya program was rated "weak" and "poor" in the international literature. The Kenya Situation Analysis Study found a functioning, integrated maternal and child health/family planning program serving large numbers of clients, with an emphasis on oral contraceptives and Depo-Provera (and an underemphasis on permanent methods). Although a number of program problems were revealed by the study, overall, in terms of performance, a rating of "moderate" is suggested as more appropriate for Kenya's national family planning program today. In terms of the quality of care, a "moderate to moderate-high" rating is suggested.