Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital

The first 100 consecutive shoulder arthroscopic procedures performed under interscalene anesthesia at a small community-sized military hospital are the basis of this report. This method of anesthesia was compared with 100 shoulder arthroscopies performed in a previous 2-year time period under general anesthesia. A variety of arthroscopic and subsequent open reconstructive procedures about the shoulder were performed using both techniques. Using the interscalene method, 87 regional blocks were entirely successful. Thirteen patients required conversion to general anesthesia for adequate pain control; however, 4 of these had a complete block in the recovery room and required no postoperative narcotics. Seven patients required supplementation with local anesthetic when an open procedure became necessary. There were no major complications. Minor complications included 5 patients with transient Horner's syndrome, 4 patients who experienced anxiety, which was controlled with sedation, and 3 with nausea or pruritus. Interscalene anesthesia provided excellent intraoperative and postoperative analgesia with low morbidity. On a subsequent questionnaire, all patients with a successful block reported that they were extremely satisfied with their experience. Ten patients who had previous shoulder surgery under general anesthesia preferred the interscalene method. In summary, interscalene anesthesia proved to be an excellent method of anesthesia for shoulder arthroscopy. The technique is reproducible within the resources available in most community-level hospitals.     

Imaging the neurobiological substrate of atypical depression by SPECT

Purpose Neurobiological abnormalities underlying atypical depression have previously been suggested. The purpose of this study was to explore differences at functional brain imaging between depressed patients with and without atypical features and healthy controls. Methods Twenty-three out-patients with chronic depressive disorder recruited from a service for patients with audiological symptoms were investigated. Eleven fulfilled the DSM-IV criteria for atypical depression (mood reactivity and at least two of the following: weight gain, hypersomnia, leaden paralysis and interpersonal rejection sensitivity). Twenty-three healthy subjects served as controls. Voxel-based analysis was applied to explore differences in ^99mTc-HMPAO uptake between groups. Results Patients in the atypical group had a higher prevalence of bilateral hearing impairment and higher depression and somatic distress ratings at the time of SPECT. Significantly higher tracer uptake was found bilaterally in the atypical group as compared with the non-atypicals in the sensorimotor (Brodmann areas, BA1–3) and premotor cortex in the superior frontal gyri (BA6), in the middle frontal cortex (BA8), in the parietal associative cortex (BA5, BA7) and in the inferior parietal lobule (BA40). Significantly lower tracer distribution was found in the right hemisphere in the non-atypicals compared with the controls in BA6, BA8, BA44, BA45 and BA46 in the frontal cortex, in the orbito-frontal cortex (BA11, BA47), in the postcentral parietal cortex (BA2) and in the multimodal association parietal cortex (BA40). Conclusion The differences found between atypical and non-atypical depressed patients suggest different neurobiological substrates in these patient groups. The putative links with the clinical features of atypical depression are discussed. These findings encourage the use of functional neuroimaging in psychiatric disorders.     

The liver in infectious mononucleosis

Summary 1. Twenty-two patients with infectious mononucleosis were studied by liver biopsy and paper electrophoresis of the serum proteins. The findings were compared with a similar group of 30 patients with infectious hepatitis.2. The essential histologic features of infectious mononucleosis were the presence in the hepatic sinusoids and portal tracts of chronic inflammatory cells resembling small lymphocytes, with essentially no parenchymal cell damage. Admixed with this lymphocytic infiltrate, but in relatively minimal numbers, were a few plasma cells and polymorphonuclear leukocytes. In addition, in infectious mononucleosis there were, with rare exceptions, no lipochrome-containing Kupffer cells. Thus, in the majority of cases, the histologic picture was distinct from that seen in infectious hepatitis. Only in comparing a few of the more severe infectious mononucleosis cases with subsiding infectious hepatitis cases was there any tendency for the two pictures to merge, and the distinction on histologic grounds between the two entities could be made in the great majority of cases.3. The most commonly seen abnormalities in the paper electrophoretic patterns of sera obtained from patients with infectious mononucleosis were decreased albumin, increased gamma globulin, not infrequent but variable changes in alpha₂ globulin, and the presence of abnormal proteins migrating with mobilities intermediate to alpha₂ and beta, and beta and gamma globulins. The abnormalities observed in infectious hepatitis were similar to those of infectious mononucleosis, except that in hepatitis alpha₂ globulin was decreased more consistently, gamma globulin increased less frequently, and beta globulin, which was normal in practically all the cases of infectious mononucleosis, was increased in a considerable number of cases.4. Treatment of patients with infectious mononucleosis need not include prolonged bed rest and restriction of activity in an effort to avoid the development of chronic liver disease.     

Thiols decrease cytokine levels and down-regulate the expression of CD30 on human allergen-specific T helper (Th) 0 and Th2 cells

The thiol antioxidant N-acetyl- L-cysteine (NAC), known as a precursor of glutathione (GSH), is used in AIDS treatment trials, as a chemoprotectant in cancer chemotherapy and in treatment of chronic bronchitis. In vitro, GSH and NAC are known to enhance T cell proliferation, production of IL-2 and up-regulation of the IL-2 receptor. The 120-kD CD30 surface antigen belongs to the tumour necrosis factor (TNF) receptor superfamily. It is expressed by activated T helper (Th) cells and its expression is sustained in Th2 cells. We have analysed the effect of GSH and NAC on the cytokine profile and CD30 expression on human allergen-specific T cell clones (TCC). TCC were stimulated with anti-CD3 antibodies in the presence of different concentrations of GSH and NAC. Both thiols caused a dose dependent down-regulation of IL-4, IL-5 and IFN-gamma levels in Th0 and Th2 clones, with the most pronounced decrease of IL-4. Furthermore, they down-regulated the surface expression of CD30, and the levels of soluble CD30 (sCD30) in the culture supernatants were decreased. In contrast, the surface expression of CD28 or CD40 ligand (CD40L) was not significantly changed after treatment with 20 m M NAC. These results indicate that GSH and NAC favour a Th1 response by a preferential down-regulation of IL-4. In addition, the expression of CD30 was down regulated by GSH and NAC, suggesting that CD30 expression is dependent on IL-4, or modified by NAC. In the likely event that CD30 and its soluble counterpart prove to contribute to the pathogenesis in Th2 related diseases such as allergy, NAC may be considered as a future therapeutic agent in the treatment of these diseases.     

A comparative study of enzyme histochemical features in the gerbilline and human cholesteatoma

Spontaneous and experimentally induced cholesteatoma in the Mongolian gerbil has been found to exhibit histopathological similarities to human aural cholesteatoma and has been suggested as an experimental model for studies of the clinical situation. In an attempt to further characterize this model, we compared experimentally induced cholesteatomas in the external auditory canal from gerbils with those of the human ear by means of a correlated histopathologic and enzyme histochemical study. The human and gerbilline cholesteatomas revealed similar histopathologic features. Even enzyme histochemically, the human and experimentally induced cholesteatomas demonstrated similar features. Thus glucose-6-phosphate dehydrogenase activity, an indicator of oxidative metabolism, was demonstrated especially in the stratum granulosum cells of the heavily orthokeratinizing squamous epithelium adjacent to the cholesteatomas. The human ear canal skin also revealed enzyme histochemical characteristics similar to the squamous epithelium lining the human cholesteatoma. The hydrolytic enzyme activity (leucyl-aminopeptidase) was strong in the connective tissue surrounding human cholesteatoma when compared with that of ear canal skin. In the gerbilline cholesteatoma, this activity was demonstrated especially in the connective tissue adjacent to eroded bone, which possibly may facilitate cholesteatoma progression. We conclude that experimentally induced cholesteatoma has both histophatological and enzyme histochemical similarities to human aural cholesteatoma and therefore it is suggested that the gerbilline model may be used for studies on the development of human cholesteatoma. Our results support the view that cholesteatoma may originate from migrated hyperkeratinizing cells from the epidermis of the tympanic membrane or the meatus.     

Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer

BACKGROUND:: In certain patients with pancreatic and biliary cancer, chemotherapymay relieve tumour-related symptoms, improve quality of lifeand possibly prolong survival. The extent of these improvementsis not completely known in spite of the extensive use of thistreatment modality. The aim of this study was to estimate anygain in the quantity and quality of life produced by chemotherapyin patients with pancreatic and biliary cancer. PATIENTS AND METHODS:: Between January 1991 and February 1995, 90 eligible patientswith pancreatic or biliary cancer were randomized to eitherchemotherapy in addition to best supportive care or to bestsupportive care. Chemotherapy was allowed in the latter groupif the supportive measures did not lead to palliation. Chemotherapywas either sequential 5-fluorouracil/leucovorin combined withetoposide (FELv) or, in elderly and poor performance patients,the same regimen without etoposide (FLv). Quality of life wasevaluated with the EORTC-QLQ-C30 instrument. RESULTS:: Mean scale scores in the QLQ-C30 improved more often/deterioratedless frequently in the chemotherapy group than in the best supportivecare group. More patients in the chemotherapy group (36%, 17/49)had an improved or prolonged high quality of life for a minimumperiod of months compared to those in the best supportive caregroup (10%, 4/41, p <0.01). Overall survival was significantlylonger in the chemotherapy group (median 6 vs. 2.5 months, p<0.01). Also, the quality-adjusted survival time was longerfor patients randomized to chemotherapy (median 4 vs. 1 months,p <0.01). The effects were seen both in pancreatic and biliarycancer. CONCLUSION:: The results show that chemotherapy can add to both quantityand quality of life in advanced pancreatic and biliary cancer.The number of patients who benefit from treatment is, however,still limited; for this reason careful selection before, andclose monitoring during, treatment are necessary. biliary cancer, chemotherapy, palliation, pancreatic cancer, randomized study     

Influence of nitrogen status on the bioconcentration of hydrophobic organic compounds to Selenastrum capricornutum

Changes in algal nitrogen status that increase algal lipid content also affect the bioconcentration of hydrophobic organic compounds (HOCs). Bioconcentration factors (BCFs) for several HOCs increased up to nine times as the total algal lipid content of the green algae Selenastrum carpricornutum increased from 17 to 44% of the algal dry weight as a consequence of nitrogen starvation. An increase in total lipid from 17 to 44% should theoretically increase the BCFs by a factor of 2.6. BCFs for PCB 31, PCB 49, PCB 153, and DDT increased with maximum lipid content by factors of 6.3, 8.9, 8.9, and 6.6, respectively, thus more than theoretically predicted from the lipid normalization of BCFs obtained at exponential growth phase (17% total lipid for S. carpricornutum), whereas BCFs for PCB 105, phenanthrene, and 4-chloroaniline increased at 44% lipid content, only by factors of 1.5, 1.5, and 2.5, respectively, and thus less than or equal to the theoretical prediction. Lipid-class normalization of BCFs did not reveal significant information beyond that available from normalizing to total lipid.     

Intestinal permeability in the newborn

Passive intestinal permeability in 33 newborn babies was studied using feeds containing lactulose and mannitol. Each marker is thought to pass across the gut wall by a different route; lactulose by a paracellular and mannitol by a transcellular pathway. Neither is metabolised and both are wholly and solely excreted by the kidney; urinary recovery is a measure of the intestinal uptake. Babies born before 34 weeks' gestation exhibited a higher intestinal permeability to lactulose than more mature babies, and all preterm babies showed an appreciable decline in lactulose absorption during the first week of oral feeds. Babies of 34 to 37 weeks' gestation achieved a 'mature' intestinal permeability to lactulose within four days of starting oral feeds. These findings may reflect the immaturity of the gut of the preterm baby rather than a process essential to adaptation to enteral nutrition.     

A novel quantitative dual-isotope method for simultaneous ventilation and perfusion lung SPET

A quantitative dual-isotope single-photon emission tomography (SPET) technique for the assessment of lung ventilation (V) and perfusion (Q) using, respectively, technetium-99m labelled Technegas (140 keV) and indium-113m labelled macro-aggregated albumin (392 keV), is presented, validated and clinically tested in a healthy volunteer. In order to assess V, Q and V/Q distributions in quantitative terms, algorithms which correct for down scattering, photon scattering and attenuation, as well as an organ outline algorithm, were implemented. Scatter and down-scatter correction were made in the spatial domain by pixel-wise image subtraction of projection-dependent global scattering factors obtained from the energy domain. The attenuation correction was based on an iterative projection/back-projection method. All studies were made on a three-headed SPET system (Trionix) with medium-energy parallel-hole collimators. The set of input data for quantification was based on SPET acquisition of emission data in four separate energy windows, the associated cumulative energy spectra and transmission data. The attenuation correction routine as well as the edge detection algorithm utilized data from (99m)Tc transmission tomography. Attenuation data for (113m)In were obtained by linear scaling of the (99m)Tc attenuation maps. The correction algorithms were experimentally validated with a stack phantom system and applied on a healthy volunteer. The mean difference between the corrected SPET data of the dense stack lung phantom and those obtained from the corresponding scatter- and attenuation-"free" version was only 1.9% for (99m)Tc and 0.9% for (113m)In. The estimated fractional V/Q distribution in the 3-D lung phantom volume had its peak at V/Q=1, with a width (FWHM) of 0.31 due to noise, particularly in the (113m)In images, and to partial volume effects. For a healthy volunteer, the corresponding values were 0.9 and 0.35, respectively. This method allows accurate assessment of radionuclide distribution on a regional basis. For basic lung physiology and clinical practice, the method allows assessment of the global frequency functions of the V, Q and V/Q distributions.