A noninvasive method of predicting pulmonary-capillary wedge pressure.

BACKGROUND. The noninvasive prediction of pulmonary-capillary wedge pressure (PCWP) is important for the recognition and treatment of a variety of cardiovascular disorders. The response of the arterial pressure to the Valsalva maneuver has been shown to correlate with the PCWP. We therefore devised a noninvasive method to measure this pressure response at the bedside and correlated these measurements with the PCWP measured directly with a pulmonary-artery catheter. METHODS. Simultaneous, blinded, noninvasive measurements of the ratio of the final amplitude to the initial amplitude of the pulse wave form during the stress phase of the Valsalva maneuver (pulse-amplitude ratio) and direct measurements of the PCWP were obtained in 20 clinically stable patients and in 14 clinically unstable patients who were receiving vasoactive agents, 12 of whom also had endotracheal tubes in place. RESULTS. Using linear regression analysis, we found that the pulse-amplitude ratio strongly correlated with the measured PCWP over a range of base-line values from 4 to 32 mm Hg for the 20 clinically stable patients (R2 = 0.80) and the 14 clinically unstable patients (R2 = 0.85). The method also correctly predicted changes in the PCWP after the administration of nitroglycerin or furosemide and after expansion of the intravascular volume (R2 = 0.79). CONCLUSIONS. These preliminary data indicate that a simple noninvasive method can accurately predict the PCWP and changes in the PCWP in response to medical therapy.     

Factors associated with hypertension in Nigerian civil servants

BACKGROUND. Study of hypertension in segments of West African populations in transition toward Westernization may lead to better understanding of the high risk for hypertension among Westernized blacks. METHODS. Five hundred fifty-nine urban civil servants, ages 25-54, were recruited from six ministries of Bendel State, Nigeria. Blood pressure, physical measurements, urinary protein and glucose, fasting blood glucose, and demographic data were collected at the workplace. Subjects were classified as senior staff (professionals or administrators) or junior staff (non-administrators). RESULTS. Among 172 male senior staff, the age-adjusted rate of hypertension (diastolic blood pressure > or = 90 mm Hg, systolic blood pressure > or = 140 mm Hg, or on an antihypertensive medication) was 43% and occurrence rose dramatically from 21 to 63% across age groups 25-34 to 45-54, respectively. Among 266 male junior staff, the age-adjusted rate of hypertension was 23%, and occurrence did not rise with age. Logistic regression showed that body mass index (kg/m2), age, alcohol drinking, and being senior staff were all independently related to hypertension in men. On the other hand, the age-adjusted rate of hypertension in 121 women was 20% and was significantly related only to body mass index. CONCLUSION. Male urban civil servants appeared to have a risk for hypertension similar to that of U.S. black males. Age, body mass index, alcohol drinking, and other unidentified factors related to higher socioeconomic status were strong determinants of hypertension in this population.     

Activity of vasoactive intestinal peptide and serotonin in the paraventricular nucleus reflects the periodicity of the endogenous stimulatory rhythm regulating prolactin secretion.

PRL secretion in the female rat is regulated by an endogenous stimulatory rhythm (ESR) of prolactin-releasing factors of hypothalamic origin which has a bimodal periodicity with distinct nocturnal (N) and diurnal (D) phases. The N phase reaches peak magnitude by 0300 h and the D phase reaches peak magnitude by 1700 h. This rhythm was first unmasked in ovariectomized rats by correctly timed injection of a dopamine antagonist. OT, vasoactive intestinal peptide (VIP), and serotonin (5-HT) are differentially involved in generating the ESR. Pharmacological studies suggest that OT is the neurohormone and VIP and 5-HT are neuromodulators which act to stimulate OT release. Recently, we reported that activity of OTergic neurons in the paraventricular nucleus (PVN) and OT concentrations in the anterior pituitary mirror the periodicity of the ESR. The present experiments were conducted to determine if VIP and 5-HT activity in the hypothalamus also mirrors the periodicity of the ESR. Push-pull cannulae were surgically implanted in the PVN of ovariectomized female rats. Following recovery, push-pull perfusion was conducted from either 0600-1400 h, 1400-2200 h, or 2200-0600 h. VIP was measured in perfusates by RIA. There was no difference in VIP pulse frequency between rats perfused during the three periods studied. However, animals perfused from 2200-0600 h had significantly greater pulse amplitude as compared to rats at either 0600-1400 h or 1400-2200 h. Activity of 5-HTergic neurons in the hypothalamus was studied by estimating the turnover of 5-HT 10 min following the injection of pargyline. Hypothalamic nuclei were dissected using Palkovits' punch technique and 5-HT concentration assayed by HPLC in conjunction with electrochemical detection. Turnover of 5-HT was estimated by calculating the slope of the accumulation of 5-HT over 10 min at differing times of day using least squares regression analysis. There was a distinct diurnal rhythm of 5-HT accumulation in the PVN. Rats killed at 1700 h had significantly greater slopes of 5-HT accumulation in the PVN than rats killed at either 0300 or 1200 h. Similarly, there was a diurnal rhythm of 5-HT turnover in the suprachiasmatic nucleus. Rats sampled at either 1200 or 1700 h had significantly greater slopes of 5-HT accumulation in the suprachiasmatic nucleus than rats sampled at 0300 h. There was no diurnal rhythm of 5-HT turnover evident in either the median eminence or the supraoptic nucleus.(ABSTRACT TRUNCATED AT 400 WORDS)     

Do anterior interbody cages have a potential value in comparison to autogenous rib graft in the surgical management of Scheuermann's kyphosis?

BACKGROUND CONTEXT: Previous studies have analyzed the outcome following posterior correction and combined anterior-posterior correction for Scheuermann's kyphosis. Traditionally interbody fusion has been obtained using morselized rib graft. Recently the use of titanium anterior cages has been suggested for interbody use. There are no long-term studies comparing these two techniques. PURPOSE: To investigate the potential value of titanium anterior interbody cages compared with morselized rib graft for anterior interbody fusion in combination with posterior instrumentation, correction, and fusion for Scheuermann's kyphosis. STUDY DESIGN: Nonrandomized comparison of two surgical techniques in matched subjects. PATIENT SAMPLE: Fifteen patients with identical preoperative radiographic and physical variables (age, gender, height, weight, body mass index) were managed with combined anterior release, interbody fusion, posterior instrumentation, correction, and fusion. Group A (n=8) had morselized rib graft inserted into each intervertebral disc space. Group B (n=7) had titanium interbody cages packed with bone graft inserted at each level. The posterior instrumentation extended from T2 to L2 in both groups. OUTCOME MEASURES: Preoperative and postoperative curve morphometry was studied on plain radiographs by two independent observers. The indices studied included Cobb angle, Ferguson's angle, Voutsinas index, sagittal vertical axis (SVA), sacral inclination (SI), and lumbar lordosis (LL). Interbody fusion was assessed at final follow-up. Each patient was reviewed at 3, 6, 12, 24, 48, and 60 months after surgery with standing radiographs. METHODS: Both surgical groups were compared in terms of radiological parameters and complications. Wilcoxon-matched pairs test and Mann-Whitney test were used. RESULTS: The average follow-up for Group A was 70 months and for Group B 66 months. For the whole group, the preoperative median Cobb angle for thoracic kyphosis was 86 degrees , the median Ferguson angle was 50 degrees , Voutsinas index was 28.7, SVA -3.5 centimeters, lumbar lordosis was 66 degrees , and the median sacral inclination angle was 40 degrees . The median postoperative Cobb angle was 42 degrees , Ferguson angle 28.4 degrees , Voutsinas index 13, SVA -4.0 centimeters, and the median sacral inclination angle was 34 degrees . There were significant differences between preoperative and postoperative measurements for all variables (p<.01), indicating that good correction was achieved. At 4-year follow-up, fusion criteria were satisfied in 12 of 15 cases (80%). Three patients had distal junctional kyphosis. There was no significant difference obtained in the final Cobb angle, Ferguson angle, and Voutsinas index when Group A (rib graft) was compared with Group B (titanium cage) Both Group A and B patients retained the postoperative correction achieved with respect to all the radiographic parameters studied. CONCLUSION: We were unable to demonstrate any significant advantage for the use of anterior titanium interbody cages over the use of morselized rib graft in the surgical management of Scheuermann's kyphosis. Given the not inconsiderable cost and the need for posterior chevron osteotomies when interbody cages are used, we have now reverted to our previous practice of using morselized rib graft at each intervertebral level.     

Tics moderate treatment outcome with sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive disorder.

BACKGROUND: The presence of a comorbid tic disorder may predict a poorer outcome in the acute treatment of pediatric obsessive-compulsive disorder (OCD). METHODS: Using data from the National Institute of Mental Health (NIMH)-funded Pediatric OCD Treatment Study (POTS) that compared cognitive-behavior therapy (CBT), medical management with sertraline (SER), and the combination of CBT and SER (COMB), to pill placebo (PBO) in children and adolescents with OCD, we asked whether the presence of a comorbid tic disorder influenced symptom reduction on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) after 12 weeks of treatment. RESULTS: Fifteen percent (17 of 112) of patients exhibited a comorbid tic disorder. In patients without tics, results replicated previously published intent-to-treat outcomes: COMB > CBT > SER > PBO. In patients with a comorbid tic disorder, SER did not differ from PBO, while COMB remained superior to CBT and CBT remained superior to PBO. CONCLUSIONS: In contrast to CBT outcomes, which are not differentially impacted, tic disorders appear to adversely impact the outcome of medication management of pediatric OCD. Children and adolescents with obsessive-compulsive disorder and a comorbid tic disorder should begin treatment with cognitive-behavior therapy alone or the combination of cognitive-behavior therapy plus a serotonin reuptake inhibitor.