POSTMYOCARDIAL INFARCTION VENTRICULAR SEPTAL RUPTURE IN THE THROMBOLYTIC ERA: TWO-YEAR EXPERIENCE AT A REGIONAL CENTRE

SUMMARY We review the 2-year experience in one cardiology unit of postmyocardial infarction ventricular septal rupture. Between July 1990 and July 1992 there were 23 such patients for whom records were available, 20 of whom underwent surgical repair. The overall mortality was 48%, and the operative mortality was 40%. The mortality in patients who suffered septal rupture within 48 hours of acute myocardial infarction was 82%, while in those in whom rupture was delayed for more than 48 hours the mortality was 17% (P<0.001). Despite a local thrombolytic rate of 75% in acute myocardial infarction, only 5 out of 23 had received thrombolytic therapy. In this centre, postinfarction septal rupture is a common reason for emergency referral. Survival in those presenting more than 48 hours after infarction is good; in those presenting earlier the prognosis remains poor, despite surgery.     

Cluster headache attacks treated for up three months with subcutaneous sumatriptan (6 mg)

In the first three months of a 24-month open study to assess the safety and efficacy of subcutaneous sumatriptan 6 mg in the long-term acute treatment of cluster headache, 138 patients treated a maximum of two attacks daily each with a single 6 mg injection. A total of 6353 attacks were treated. Adverse events, reported in 28% of sumatriptan-treated attacks, were qualitatively similar to those seen in migraine long-term trials. Their incidence did not increase with frequent use of sumatriptan. There were no clinically significant treatment effects on vital signs, ECG recordings or laboratory parameters. Headache relief (a reduction from very severe, severe or moderate pain to mild or no pain) at 15 min was obtained for a median of 96% of attacks treated. There was no indication of tachyphylaxis, decrease in the speed of response, or increased frequency of attacks with long-term treatment. This study demonstrated that, in long-term use, subcutaneous sumatriptan 6 mg is a well-tolerated and effective acute treatment for cluster headache.     

静脉注射同种异体骨髓间充质干细胞对血管性痴呆大鼠海马区脑组织形态及微管相关蛋白2表达的影响

目的:骨髓间充质干细胞移植进入脑组织后,能否影响脑组织的形态及微管相关蛋白2的表达从而改善痴呆状态下的认知功能?观察静脉注射同种异体骨髓间充质干细胞后,血管性痴呆模型大鼠脑海马CA1区脑组织形态及微管相关蛋白2的变化。方法:实验于2004-08/2005-05在解放军第二军医大学完成。①实验动物:健康雄性SD大鼠60只,随机数字表法分为细胞移植组、模型对照组、假手术组,20只/组。②实验方法:另取20只大鼠用于体外分离、培养扩增骨髓间充质干细胞,传至第2代时加入BrdU进行标记,制备单细胞悬液,调整细胞浓度为3×109L-1。细胞移植组、模型对照组采用双侧颈总动脉结扎法建立血管性痴呆动物模型,假手术组仅暴露双侧颈总动脉但不结扎。造模后4周,细胞移植组尾静脉注射骨髓间充质干细胞悬液1mL,模型对照组注射等量磷酸盐缓冲液,假手术组不进行尾静脉注射。③实验评估:细胞移植后4周,苏木精-伊红染色检测各组大鼠脑海马CA1区脑组织形态变化,免疫荧光染色观察经BrdU标记的骨髓间充质干细胞示踪情况,免疫组织化学染色检测脑海马CA1区微管相关蛋白2的表达。结果:细胞移植组5只大鼠死亡,模型对照组3只大鼠死亡,假手术组均进入结果分析。①脑海马CA1区锥体细胞形态变化:细胞移植组和模型对照组CA1区锥体细胞较假手术组排列稀疏、紊乱,细胞肿胀、脱失,核固缩,但细胞移植组细胞排列较模型对照组规则,且细胞肿胀、脱失及核固缩较模型对照组减轻。②脑海马内骨髓间充质干细胞的示踪:细胞移植后4周,大鼠脑海马内可见被绿色荧光标记的骨髓间充质干细胞。③脑海马CA1区微管相关蛋白2的表达:与假手术组比较,细胞移植组及模型对照组脑海马CA1区锥体细胞层微管相关蛋白2阳性产物的吸光度值均明显降低(P<0.05);细胞移植组明显高于模型对照组(P<0.05)。结论:静脉注射骨髓间充质干细胞能够使血管性痴呆大鼠脑海马CA1区神经元损伤及脱失减轻,并使微管相关蛋白2表达增加。     

Differential distribution of 5HT1D- and 5HT1B-immunoreactivity within the human trigemino-cerebrovascular system: implications for the discovery of new antimigraine drugs

Sumatriptan, a 5HT_1B/1D-receptor agonist, is clinically effective as an antimigraine agent. Its therapeutic action may result partly from vasoconstriction of excessively dilated cranial blood vessels (a 5HT_1B-receptor mediated response). The antimigraine activity of sumatriptan may also result from inhibition of the release of vasoactive neuropeptides from trigeminal sensory fibres within the meninges. The identity of the 5HT_1B/1D-receptor subtype mediating this effect is unknown. Using 5HT_1D- and 5HT_1B-receptor-specific antibodies we have demonstrated a differential distribution of these receptor subtypes within the human trigemino-cerebrovascular system. Only 5HT_1B-receptor protein was detected on dural arteries. In contrast, only 5HT_1D-receptor protein was detected on trigeminal sensory neurones including peripheral and central projections to dural blood vessels and to the medulla. Within the medulla 5HT_1D-receptor protein was confined to discrete areas associated with the trigeminal sensory system. These findings have important implications for the design of new antimigraine drugs.     

Improving mortality outcomes of Stevens Johnson syndrome/toxic epidermal necrolysis: A regional burns centre experience

Introduction

Stevens Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN) are rare, potentially fatal desquamative disorders characterised by large areas of partial thickness skin and mucosal loss. The degree of epidermal detachment that occurs has led to SJS/TEN being described as a burn-like condition. These patients benefit from judicious critical care, early debridement and meticulous wound care. This is best undertaken within a multidisciplinary setting led by clinicians experienced in the management of massive skin loss and its sequelae. In this study, we examined the clinical outcomes of SJS/TEN overlap & TEN patients managed by our regional burns service over a 12-year period. We present our treatment model for other burn centres treating SJS/TEN patients.

Transjugular intrahepatic portosystemic shunt as a treatment for protein-losing enteropathy caused by portal hypertension

A case of a 41-year-old man with diarrhea, hypoalbuminemia, and cryptogenic cirrhosis with features of portal hypertension is described. Protein-losing enteropathy was confirmed by analysis of whole-gut lavage fluid, and intestinal inflammation and infection were excluded. Distal duodenal biopsy specimens showed evidence of edematous villi with prominent submucosal vascular and lymphatic vessels. A transjugular intrahepatic portosystemic stent-shunt was inserted, resulting in resolution of both his diarrhea and elevated whole gut lavage fluid protein concentrations. His symptoms recurred and then again improved after shunt thrombosis and parallel shunt placement, respectively. Histological improvement of the villous edema was also noted. This is the first recorded case of protein-losing enteropathy caused by portal hypertension confirmed by successful treatment with transjugular intrahepatic portosystemic stent-shunt. (Gastroenterology 1996 Dec;111(6):1679-82)     

Hairy cell identification by immunohistochemistry of tartrate-resistant acid phosphatase

Tartrate-resistant acid phosphatase (TRAcP) has been an indispensible marker for hairy cell leukemia (HCL) for over two decades. However, the traditional TRAcP cytochemical stain cannot be performed effectively on sections of paraffin-embedded tissues that are important resources for histopathologic evaluation in diagnosis and treatment of HCL. Wide variation in expression of TRAcP activity by hairy cells (HCs) within and among patients is an interesting biologic phenomenon that has not been explained and can cause some diagnostic uncertainty as well. To solve the problem of staining TRAcP in paraffin sections and to begin to address the questions of variable TRAcP expression in HCL, we developed a monoclonal antibody to TRAcP, 9C5, for immunohistochemical identification of HCs. In smears of blood and bone marrow, immunocytochemistry of TRAcP using 9C5 was as specific but slightly less sensitive than direct cytochemical staining of enzymatic activity. In paraffin sections of spleen and bone marrow from HCL patients, immunohistochemistry with 9C5 stained the HCs with high sensitivity and specificity and clearly showed the characteristic diffuse infiltration by HCs. Other cells noted to stain strongly with 9C5 were occasional macrophages in bone marrow smears and osteoclasts and occasional tissue macrophages in paraffin sections. These are cells known to express abundant TRAcP activity. Immunohistochemistry with anti-TRAcP monoclonal antibody 9C5 may have utility as an added option in the diagnosis of HCL, as a means to evaluate residual disease in HCL patients undergoing new treatments, and as a way to address questions regarding variable expression of TRAcP activity by HCs within and among patients with HCL. Also, 9C5 has potential as a reagent for the immunoassay of bone-derived serum TRAcP in patients with certain bone diseases and cancers with bone metastasis.     

Lack of protective effect of autotransplanted splenic tissue to pneumococcal challenge

Studies in animals and clinical experience in patients have demonstrated that splenectomy may lead to an increased susceptibility to infection. The infections are usually caused by encapsulated bacteria such as penumococcus. It has been shown in a variety of experimental animals that autotransplanted splenic tissue is capable of regenerating into implants that are microscopically indistinguishable from normal spleen and of restoring a number of normal splenic functions. The response to intravenous challenge with Streptococcus pneumoniae, type 25, was therefore studied in control, asplenic, and autotransplanted Sprague-Dawley rats. Despite previous observations that a number of immune functions can be restored in this animal model by autotransplanted splenic tissue, the present study indicates that splenic tissue autotransplants do not restore the ability to resist intravenous pneumococcal challenge.     

An Integrated Service Delivery Model to Identify Persons Living with HIV and to Provide Linkage to HIV Treatment and Care in Prioritized Neighborhoods: A Geotargeted,Program Outcome Study

Background

Recent studies have demonstrated that high human immunodeficiency virus (HIV) prevalence (2.1%) rates exist in “high-risk areas” of US cities that are comparable to rates in developing nations. Community-based interventions (CBIs) have demonstrated potential for improving HIV testing in these areas, thereby facilitating early entry and engagement in the HIV continuum of care. By encouraging neighborhood-based community participation through an organized community coalition, Project LINK sought to demonstrate the potential of the CBI concept to improve widespread HIV testing and referral in an area characterized by high poverty and HIV prevalence with few existing HIV-related services.

Objective

This study examines the influence of Project LINK to improve linkage-to-care and HIV engagement among residents of its target neighborhoods.

Methods

Using a venue-based sampling strategy, survey participants were selected from among all adult participants aged 18 years or more at Project LINK community events (n=547). We explored multilevel factors influencing continuum-of-care outcomes (linkage to HIV testing and CBI network referral) through combined geospatial-survey analyses utilizing hierarchical linear model methodologies and random-intercept models that adjusted for baseline effect differences among zip codes. The study specifically examined participant CBI utilization and engagement in relation to individual and psychosocial factors, as well as neighborhood characteristics including the availability of HIV testing services, and the extent of local prevention, education, and clinical support services.

Results

Study participants indicated strong mean intention to test for HIV using CBI agencies (mean 8.66 on 10-point scale [SD 2.51]) and to facilitate referrals to the program (mean 8.81 on 10-point scale [SD 1.86]). Individual-level effects were consistent across simple multiple regression and random-effects models, as well as multilevel models. Participants with lower income expressed greater intentions to obtain HIV tests through LINK (P<.01 across models). HIV testing and CBI referral intention were associated with neighborhood-level factors, including reduced availability of support services (testing P<.001), greater proportion of black/African Americans (testing and referral P<.001), and reduced socioeconomic capital (testing P=.017 and referral P<.001). Across models, participants expressing positive attitudes toward the CBI exhibited greater likelihood of engaging in routine HIV testing (P<.01) and referring others to HIV care (P<.01). Transgender individuals indicated greater intent to refer others to the CBI (P<.05). These outcomes were broadly influenced by distal community-level factors including availability of neighborhood HIV support organizations, population composition socioeconomic status, and high HIV prevalence.

Conclusions

Project LINK demonstrated its potential as a geotargeted CBI by evidencing greater individual intention to engage in HIV testing, care, and personal referrals to its coalition partner organizations. This study highlights important socioecological effects of US-based CBIs to improve HIV testing and initiate acceptable mechanisms for prompt referral to care among a vulnerable population.