Verrucous lesions in patients with discoid lupus erythematosus

Seven cases of classical discoid lupus erythematosus of the face associated with hyperkeratotic, papulo-nodular lesions on the arms and hands were studied. Clinically the hyperkeratotic lesions resembled keratoacanthomas or hypertrophic lichen planus. The clinical course was marked by chronicity, an absence regression of the lesions, and resistance to treatment. Histopathologically, a lichenoid cellular reaction seemed to play a key role in the development of the hypertrophic lesions which resembled either keratoacanthomoas or hypertrophic lichen planus. Elastic fibres were prominent in the upper dermis, the lower levels of the epidermis and in the hyperkeratotic horny layer. Immunofluorescence of the papulo-nodular lesions demonstrated the deposition of IgG and IgM in a globular pattern at the dermal-epidermal junction. Discontinuous deposition of these antibodies was also seen at the basement membrane zone. On the basis of the immunofluorescence, histopathological and clinical studies, we suggest that the verrucous, hyperkeratotic lesions on the upper extremities represent an unusual, but distinct, form of discoid lupus erythematosus.     

Postural Tachycardia Syndrome (POTS)

Introduction: POTS is defined as the development of orthostatic symptoms associated with a heart rate (HR) increment ≥30, usually to ≥120 bpm without orthostatic hypotension. Symptoms of orthostatic intolerance are those due to brain hypoperfusion and those due to sympathetic overaction.
Methods: We provide a review of POTS based primarily on work from the Mayo Clinic.
Results: Females predominate over males by 5:1. Mean age of onset in adults is about 30 years and most patients are between the ages of 20–40 years. Pathophysiologic mechanisms (not mutually exclusive) include peripheral denervation, hypovolemia, venous pooling, β-receptor supersensitivity, psychologic mechanisms, and presumed impairment of brain stem regulation. Prolonged deconditioning may also interact with these mechanisms to exacerbate symptoms. The evaluation of POTS requires a focused history and examination, followed by tests that should include HUT, some estimation of volume status and preferably some evaluation of peripheral denervation and hyperadrenergic state. All patients with POTS require a high salt diet, copious fluids, and postural training. Many require β-receptor antagonists in small doses and low-dose vasoconstrictors. Somatic hypervigilance and psychologic factors are involved in a significant proportion of patients.
Conclusions: POTS is heterogeneous in presentation and mechanisms. Major mechanisms are denervation, hypovolemia, deconditioning, and hyperadrenergic state. Most patients can benefit from a pathophysiologically based regimen of management.     

Cost and Length of Hospital Stay: Comparisons Between Nonthoracotomy and Epicardial Techniques in Patients Receiving Implantable Cardioverter Defibrillators

Twenty-five patients with implantable Cardioverter defibrillators (ICDs) implanted intrathoracically (group I) were compared with 25 patients who underwent implant using the nonthoracotomy approach (group II). AH systems were implanted by the same medical team, in the same high volume implanting center. Indications for implantation were comparable in both groups. Patient characteristics were not statistically different with the exception of age fee-group I vs 71-group II; P < 0.05). Although left ventricular ejection fractions appeared to differ (32% vs 37%, respectively), this difference was not statistically significant (P = 0.06). ICD models used in group I were: Ventritex Cadence (16), Telectronics Guardian 4211 (2), Medtronic PCD (7); in group II they were: Ventritex Cadence (15), Guardian 4211 (2), and CPI 1600 (1). Total length of hospital stay was 16 ± 6 days for group I versus 12 ± 5 for group II (P < 0.05). Number of postoperative days in an intensive care unit was 3.2 ± 2.8 for group I versus 0.5 ± 0.6 for group II (P < 0.0001). Postoperative length of stay was 8.2 ± 3.1 for group I versus 5.7 ± 4.4 for group II (P < 0.001). Mean total hospital charges for the entire length of stay were $72,918 ±$26,770 in group I versus $55,031 ±$42,870 in group II, representing a mean reduction of 21 % in global costs for group II patients. These data confirm that nonthoracotomy ICD implantation in an experienced center is associated with significantly shorter hospital stays, a virtual elimination of the need for postoperative intensive care, and globally lower total hospital costs. In addition, the presence of a statistically older population in group II does not negate these beneficial effects.     

Fetal umbilical artery flow velocity waveforms and placental resistance: pathological correlation

Summary. Placental microvascular anatomy was correlated with antenatal assessment of the umbilical circulation in 106 patients to further validate the measurement of the A/B ratio (the ratio of peak systolic to least diastolic flow velocity) of the umbilical artery flow velocity time wave-forms as an index of blood flow resistance. Three groups of patients were studied: a normal group of 38 uncomplicated pregnancies, a control group of 33 potentially 'at risk' pregnancies with a normal A/B ratio matched by risk factors and gestation with the third group of 35 pregnancies with a high A/B ratio. Placental arterial resistance was quantitated by counting the number of small muscular arteries (<90 μm diameter) in the tertiary stem villi in a standard microscopic field (mean 18·5 fields/placenta). The modal small arterial vessel count was shown to be significantly less in the group with a high fetal risk and a high A/B ratio (1–2 arteries/field) than in both the normal and control groups (7–8 arteries/field). The tertiary villus count did not vary between groups. Antenatal studies of umbilical artery flow velocity waveforms with Doppler ultrasound identify a specific microvascular lesion in the placenta characterized by obliteration of small muscular arteries in the tertiary stem villi.     

Teratological Assessment of Methanol and Ethanol at High Inhalation Levels in Rats

Teratological Assessment of Methanol and Ethanol at High InhalationLevels in Rats. NELSON, B. K., BRIGHTWELL, W. S., MACKENZIE,D. R., KHAN, A., BURG, J. R., WEIGEL, W. W., AND GOAD, P. T.(1985). Fundam. Appl. Toxicol. 5, 727–736. Alcohols arewidely used as industrial solvents. In spite of the fact thatethanol is a human teratogen, there has not been systematicinvestigation of the potential teratogenic effects of otheralcohols, particularly using the inhalation route of exposure,as would be appropriate in assessing occupational and environmentaltypes of experience. As part of a large teratological examinationof industrial alcohols, methanol and ethanol were administeredby inhalation to groups of approximately 15 pregnant Sprague-Dawleyrats. Methanol was administered at 20,000 ppm (20ME), 10,000ppm (10ME), 5000 ppm (5ME), and 0 ppm (MECO) for 7 hr/day onDays 1–19 of gestation (Days 7–15 for 20ME). Ethanolwas administered at 20,000 ppm (20ET), 16,000 ppm (16ET), 10,000ppm (10ET), and 0 ppm (ETCO) for 7 hr/day on Days 1–19of gestation. Dams were sacrificed on Day 20 (sperm=Day 0).One-half of the fetuses were examined using the Wilson techniquefor visceral defects, and the other half were examined for skeletaldefects. The highest concentration of methanol (20ME) producedslight maternal toxicity and a high incidence of congenitalmalformations (p < 0.001), predominantly extra or rudimentarycervical ribs and urinary or cardiovascular defects. Similarmalformations were seen in the 10ME group, but the incidencewas not significantly different from controls. No adverse effectswere noted in the 5ME group. Dams in the 20ET group were narcotizedby the end of exposure, and maternal weight gain and feed intakewere decreased during the first week of exposure. The 16ET damshad slightly depressed weight gain (p < 0.01) during thefirst week of exposure, but there were no significant effectson feed consumption. There was no definite increase in malformationsat any level of ethanol, although the incidence in the 20ETgroup was of borderline significance     

Developmental Toxicity of Amesergide Administered by Gavage to CD Rats and New Zealand White Rabbits

Amesergide is a selective serotonin 5-HT_IC/2 receptor antagonistbeing developed for the treatment of depression. The potentialdevelopmental toxicity of amesergide was evaluated in CD ratsand New Zealand white rabbits. Pregnant rats and rabbits weredosed once daily by gavage on Gestation Days 6–17 and6–18, respectively. Doses for rats were 0, 3, 10, and30 mg/kg; doses for rabbits were 0, 0.2, 2, and 15 mg/kg. Cesareansections were performed on rats and rabbits on Gestation Days20 and 28, respectively. In rats, maternal effects expressedas depression of body weight gain and food consumption wereobserved at the 30 mg/kg dose level. Fetal viability and morphologywere not affected at any dose level. Fetal weight was depressedat the 30 mg/kg dose level. The no-observed-effect level (NOEL)in the rat was 10 mg/kg. In rabbits, maternal effects expressedas a decrease in food consumption occurred at the 2 and 15 mg/kgdose levels; weight gain was depressed at 15 mg/kg. Fetal viability,weight, and morphology were not affected at any dose level.The NOELs for maternal and developmental effects in the rabbitwere 0.2 and 15 mg/kg, respectively.