CT evaluation of atypical hepatic fatty metamorphosis

Focal fatty metamorphosis of the liver is a well-recognized entity characteristically demonstrated by a nonspherical, low-density area without mass effect. We present a case of focal fatty metamorphosis of the liver that shows multiple areas of low attenuation within the liver with mass effect. Radionuclide liver-spleen scan shows multiple focal defects corresponding to the areas of fatty metamorphosis.     

An aggressive surgical approach to bile duct cancer

Fifty-five patients with bile duct carcinoma have been treated at the Vanderbilt University, Metropolitan Nashville General, and Baptist Hospitals since 1957. Thirty-eight per cent (21) of the patients had tumors arising in the upper third of the bile duct; eight (15%) were in the middle third, and ten (18%) were in the lower third. In 12 instances, the malignant process involved both the middle and lower thirds of the bile duct, and in four cases, the extent of the tumor was too great to determine its origin. Most patients (49) presented with jaundice. Thirty (54%) also had pain, and 43 (24%) had experienced some weight loss. Fifteen had hepatomegaly, but only eight were found to have an enlarged gallbladder upon physical exam. Four patients (7%) had a positive history for hepatitis. Resection of the tumor was possible in 19 patients (35%). Decompressive procedures and biopsies were done in 25 of the others. Decompression was not possible in 11 patients. Survival for the 11 patients whose tumors were only biopsied averaged 4.6 months. Of the 25 patients who had palliative decompression, average survival has been 7.7 months. The 19 patients who had resection of their tumors survived an average of 2.08 years. Six of these patients are alive from 1-9 years post-diagnosis. Recently, a more aggressive surgical approach to bile duct carcinoma has been successful and has affected possible cure in ten patients of 19 in whom resection was possible and offered prolonged palliation to many of the other patients.     

Airway injuries. The first priority in trauma

During the last 12 years, 20 patients with significant airway injuries have been treated for lesions involving the trachea, larynx, and/or bronchus. Fourteen of the injuries were the result of penetrating wounds, nine gunshot wounds, and five stab wounds. Six patients presented with blunt trauma, four as a result of motor vehicle accidents, one from a clothesline injury, and one from a crush injury. Sixteen of the 20 were males; average age was 29.6 years. Eleven patients had injuries involving only the trachea, six had isolated laryngeal injuries, two had bronchial injuries, and one patient had a combined injury of the trachea and larynx. Eleven had subcutaneous emphysema, four had hemoptysis, and three stable patients experienced sudden respiratory arrest while being evaluated for the repair of their injuries. Twelve patients required immediate intubation or tracheostomy. Most airway injuries were closed primarily. In one instance segmental resection of a perforated trachea and primary anastomosis was necessary. Two patients died after proper management of the airway injury. One died of an associated brain stem injury and the other of profuse hemorrhage from a liver injury. Of the 18 surviving patients, all but two recovered totally without residual impairment. Described here is a protocol for the evaluation and immediate treatment of airway injuries that is consistent with the guidelines of the Subcommittee of Advanced Trauma Life Support of the American College of Surgeons Committee on Trauma. Aggressive initial management, high index of suspicion for injury, and meticulous repair of the injured airway are equally important steps in the successful management of these patients.     

Design and Objectives of the Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) Study

Clinical trials have demonstrated the efficacy of glycoprotein (GP) IIb/IIIa antagonists in preventing the thrombotic end points of death, myocardial infarction, and urgent revascularization when they are administered at the time of percutaneous coronary revascularization (PTCR). It has been postulated that prolongation of receptor blockade beyond acute intervention would extend the clinical benefit of these agents. The Evaluation of Oral Xemilofiban in Controlling Thrombotic Events (EXCITE) study was a multicenter, international, randomized placebo-controlled trial of the oral GP IIb/IIIa antagonist Xemilofiban administered prior to and after PTCR. The study was designed to assess the efficacy and safety of continuing oral xemilofiban for 6 months to prevent these primary thrombotic end points. More than 7,200 patients were randomized in 29 countries to receive placebo or one of two doses of xemilofiban. Stenting was performed at the discretion of the operator. All patients received aspirin and periprocedural heparin; all stented patients received continuous xemilofiban, or ticlopidine for 2–4 weeks followed by xemilofiban-placebo. Most patients were also evaluated 1 month after conclusion of the study drug treatment. Clinical data from up to 6 months of drug treatment and 1 month posttreatment were used to evaluate the acute and long-term efficacy and safety of xemilofiban. Secondary end points included the need for any revascularization, repeat hospitalization for unstable angina, and nonhemorrhagic stroke. The cumulative incidence of bleeding events and effects of xemilofiban in stented and nonstented patients were evaluated. The efficacy of continuing xemilofiban and aspirin therapy as the sole antithrombotic medications following stent deployment was assessed against a ticlopidine and aspirin control group. The incremental clinical benefit of long-term receptor blockade over acute receptor antagonism was evaluated.     

Human buccal absorption of flurbiprofen

The buccal absorption of flurbiprofen was studied in normal men to quantify the transport from the oral cavity in humans and to evaluate the closed-perfusion cell apparatus as a means to study drug transport across externally accessible biologic membranes. Flurbiprofen was buccally absorbed by a passive diffusional mechanism and the rate of absorption was pH dependent. Membrane permeability coefficients for flurbiprofen were 4.3 x 10(-4) cm/sec at pH 5.5 and 2.1 x 10(-5) cm/sec at pH 7.0. These findings are in agreement with the pH relationship for buccal transport observed in dog experiments. Delineation of the effective permeability coefficients into components for the aqueous boundary layer and the lipoidal buccal membrane allowed for the prediction of the extent of absorption of the drug over a period of time. It was concluded that the buccal membranes of the human and dog were essentially lipoidal membranes with equivalent permeabilities and no evident aqueous pore pathways.     

Aging with spinal cord injury: changes in selected health indices and life satisfaction

OBJECTIVES: To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes. DESIGN: Retrospective cross-sectional and longitudinal examination of people with SCI. SETTING: Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System. PARTICIPANTS: People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year. RESULTS: The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome. CONCLUSIONS: Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.     

High incidence of Pellethane 90A lead malfunction.

AIMS: The long-term performance of Pellethane 80A (P80A) endocardial pacing leads has previously been called into question. We report our experience with an endocardial pacemaker lead with silicone outer and Pellethane 2363-90A (P90) inner insulator. METHODS: Between November 1993 and March 1998, 129 P90A and 189 non-P90A ventricular leads were implanted. Lead malfunction was defined as > or = 25%) deviation in lead impedance or a two-fold reduction in sensing threshold during follow-up. Sensing and capture thresholds and lead impedance were assessed intraoperatively, immediately postoperatively, at 24 h and 6-12 weeks following implant and semiannually thereafter. Adequacy of lead positioning and lead-header interface were documented radiographically in each case. RESULTS: During 204 patient years of follow-up, 10/129 (8%) Oscor RX P90A leads malfunctioned. Average time to malfunction was 14 +/- 11 months. During 166 patient years of follow-up, none of the 189 non-P90A ventricular leads met criteria for malfunction (P < 0.05). There was no difference in patient age, sex, and arrhythmia indication between groups. Sensing problems were overcome with pacemaker reprogramming. CONCLUSION: We conclude that Oscor RX passive fixation ventricular leads with external silicone and inner P90A insulation exhibit an 8%, insulation malfunction rate within 14 +/- 11 months of implant. This is significantly higher than non-P90A leads implanted with identical technique and follow-up regimen. More frequent follow up may be warranted in patients with P90A containing leads.     

Ecology and management of whitefly-transmitted viruses of vegetable crops in Florida

A variety of fresh market vegetables, including watermelon and tomato are economically important crops in Florida. Whitefly-transmitted Squash vein yellowing virus (SqVYV) was first identified in squash and watermelon in Florida in 2005 and shown to cause a severe decline of watermelon vines as crops approach harvest. Florida is most economically impacted by SqVYV, although the virus has been detected more recently in Indiana and South Carolina. The origin and evolutionary history of SqVYV, one of the few members of the genus Ipomovirus within the family Potyviridae, are not known. Sequence diversity of SqVYV isolates collected at different times, from different locations and from different plant species is being analyzed for insights into the origin of the virus. More recently, Cucurbit leaf crumple virus (CuLCrV) and Cucurbit yellow stunting disorder virus (CYSDV), also whitefly-transmitted, have been detected in watermelon in Florida. Tomato yellow leaf curl virus (TYLCV) was first detected in south Florida tomato crops in 1997. Several surveys have been conducted in the region to identify alternative hosts for these four viruses. Cucurbit weeds including Balsam-apple (Momordica charantia), creeping cucumber (Melothria pendula) and smellmelon (Cucumis melo var. dudaim) provide reservoirs for SqVYV, CuLCrV and/or CYSDV. Green bean (Phaseolus vulgaris) also can be a reservoir for CuLCrV. No wild hosts of TYLCV have been reported in Florida. The effectiveness of insecticides and silver plastic mulch to manage whiteflies and mitigate TYLCV has been demonstrated and is currently being evaluated for SqVYV, CuLCrV and CYSDV. In addition, potential sources of SqVYV resistance have been identified in greenhouse and field screening of watermelon germplasm. Further studies to refine these sources of resistance are underway. Lastly, a comprehensive map of 33,560 hectares (82,928 acres) of vegetable fields in the three counties comprising the majority of the southwest Florida vegetable production area has been developed to identify 'hot spots' and reservoir crops for viruses and whiteflies, and will be useful in evaluation of management strategies to decrease virus incidence in commercial fields.