Clinical evaluation in therapy of patients with atrial fibrillation or flutter

The weight of evidence clearly indicates that both atrial fibrillation and atrial flutter are due to a reentrant mechanism. Atrial fibrillation seems almost certainly due to multiple circulating reentrant wavelets of the leading circle type, whereas atrial flutter appears to be caused by single reentrant circuit located in the right atrium. The diagnosis of both atrial fibrillation and atrial flutter should always be possible using either old or new techniques. The interruption of atrial flutter should be possible using pacing or direct current cardioversion techniques, and the conversion of atrial fibrillation to sinus rhythm also is most often possible by direct current cardioversion or antiarrhythmic drug therapy. Long-term antiarrhythmic drug therapy to suppress recurrent atrial fibrillation and atrial flutter may be a problem, but availability of newer antiarrhythmic agents holds promise for finding an effective regimen. Catheter ablation techniques may be used to cause complete heart block in the treatment of either atrial fibrillation or atrial flutter when these rhythms cannot be satisfactorily suppressed and are associated with unacceptably rapid ventricular response rates. Finally, recent data suggest that atrial flutter may be successfully treated on a chronic basis with an antitachycardia pacing device, may be cured with catheter ablation techniques applied to a critical portion of the atrial flutter reentry circuit, and may be treated successfully with innovative surgical techniques. The latter is also true for atrial fibrillation.     

Transient synovitis of the hip in children: role of US

Transient synovitis of the hip remains a common diagnostic problem for the clinician. The physical signs are not pathognomonic of the condition, and the classic technical examinations are of little help. Therefore, the authors retrospectively studied the value of hip arthrosonography in 46 children with clinical symptoms suggesting pathologic hip conditions. In 20 of the 21 patients with a final diagnosis of transient synovitis, articular effusion was detected on ultrasound (US). Conventional radiography showed an increased medial joint space in only eight of these patients. Increased echogenicity of the articular fluid was found in both transient synovitis and septic arthritis. The high sensitivity of US in detecting intraarticular fluid was demonstrated by cadaver studies.     

IgA synthesis by lymphocytes from patients with IgA nephropathy and their relatives

To investigate the hypothesis that a predisposition to IgA nephropathy (IgAN) is linked to the major histocompatibility complex (MHC) and associated with poorly regulated IgA synthesis, we performed HLA typing and lymphocyte cultures on patients with IgAN and their relatives. Nineteen of 22 patients had elevated culture supernatant IgA concentrations (620 vs. 154 ng/2 X 10(6) cells, P = 0.007). Supernatant IgG and IgM were normal. No HLA antigen occurred with increased frequency in patients. There was an increased incidence of homozygous null C4 alleles in patients (P less than 0.01). In families, six of 11 mothers, six of 12 fathers, and seven of 15 siblings had elevated supernatant IgA concentrations. There was no segregation of abnormal IgA production with any HLA antigen or parental haplotype. The data confirm elevated in vitro IgA production by lymphocytes from patients with IgAN, but do not support a linkage with the MHC. The increased incidence of homozygous null C4 alleles may result from functional differences in C4 A and B gene products. The familial clustering of elevated IgA production without an obvious inheritance pattern suggest that shared environmental factors may be important in the development of IgAN.     

Utilization of the extended rectus abdominis myofasciocutaneous free flap in upper extremity reconstruction

Degloving injuries of the upper extremity may require extensive soft tissue coverage. Free tissue transfer is often useful in the management of these injuries. We describe the use of an extended rectus abdominis myofasciocutaneous vascularized free flap in the management of a massive longitudinal upper extremity traumatic soft tissue defect.     

Renal artery stenosis: evaluation with intravenous digital subtraction angiography

The ability of diagnostic intravenous digital subtraction angiography (IVDSA) to demonstrate the degree of renal artery stenosis was compared with that of intraarterial angiography in 45 patients with 92 arteries. Stenotic lesions on both IVDSA and intraarterial studies were classified as normal (0% stenosis), minor (less than 50%), low grade (50%-80%), and high grade (80%-99%). There was agreement about the degree of stenosis in 90% of the cases. IVDSA grading was correct in 94% of atheromatous lesions and in 56% of the fibromuscular dysplastic lesions. In the high-grade atheromatous lesions, the degree of stenosis was slightly overestimated on IVDSA studies in 22.5% of the cases. In fibromuscular dysplasia, stenosis was underestimated in 33% of the cases.     

Hypnotically induced auditory hallucinations and the mouth-opening maneuver: a failure to duplicate findings

OBJECTIVE: The authors sought to replicate the part of a study by Bick and Kinsbourne in which hypnotically induced auditory hallucinations in normal volunteer subjects were abolished by requiring the subjects to open their mouths. METHODS: Sixty-four normal volunteer subjects were hypnotized, and an attempt was made to induce auditory hallucinations. The subjects in whom hallucinations were successfully induced were then asked to perform the mouth-opening maneuver and the control maneuvers of putting their fingers in their ears or squeezing their eyes shut in an effort to end the hallucinations. RESULTS: Sixteen subjects reported having hallucinations. None of them reported that a hallucination was abolished by opening the mouth or closing the eye; four reported ending hallucinations by putting their fingers in their ears. CONCLUSIONS: Opening the mouth does not affect auditory hallucinations induced by hypnosis in normal persons. The most likely reason for the discrepancy between the results of this experiment and those of the Bick and Kinsbourne study is that the design of the latter study was faulty because it permitted demand characteristics to influence the results.     

STREPTOCOCCAL ANTIBODY CROSS-REACTIVITY WITH HLA-DR4+VE B-LYMPHOCYTES. BASIS OF THE DR4 ASSOCIATED GENETIC PREDISPOSITION TO RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE?

B-lymphocytes obtained from patients with either rheumatic feveror rheumatic heart disease and from normal subjects were reactedwith serum obtained from rabbits immunized with streptococcalcell wall antigen. The presence of cytotoxicity was sought usingan inverted phase microscope after differential uptake of eosindye. The serum was found to be significantly more cytotoxicto HLA-DR4 containing cells of both patients and normals comparedwith DR4 negative cells (P<0. 0001). KEY WORDS: Streptococcal cell wall antigen, Antiserum, Cytotoxicity