The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction

In 422 patients admitted from the emergency department (ED) for suspected acute myocardial infarction, the hypothesis that chest pain that persists on arrival in the ED or recurs during the initial ED evaluation is a useful predictor of acute myocardial infarction (AMI) and complications of coronary ischemia was tested. Compared with patients whose chest pain spontaneously ceased before arrival in the ED, patients whose chest pain persisted or recurred during the initial ED evaluation had a 2.3 times greater risk of interventions (P less than .001), a 1.7 times greater risk of complications (P = .045), a 3.8 times greater risk of life-threatening complications (P = .04), and a 2.4 times greater risk of AMI (P = .005). A third group of patients with suspected AMI never experienced chest pain. This group of patients who never experienced chest pain had a three times higher risk of death (P = .02) compared with patients whose chest pain persisted or recurred in the ED, and a 2.1 times greater risk of intervention (P = .01), a 5.2 times greater risk of life-threatening complication (P = .015), and a 7.9 times greater risk of death (P = .025) compared with patients whose chest pain resolved before arrival in the ED. It was concluded that patients with chest pain that resolves spontaneously before arrival to the ED have a better in-hospital prognosis than any other group.     

Portal thrombosis: Percutaneous transhepatic treatment with urokinase — A case report

We present a case report of a patient suffering from portal and superior mesenteric vein thrombosis secondary to splenectomy. No surgical procedure could be performed due to the extension of thrombus.Local fibrinolysis treatment with urokinase through a percutaneous transhepatic approach was decided upon, and this procedure had a successful patient outcome.     

Beta-2 microglobulin and amyloid osteoarthropathy in patients undergoing chronic hemodialysis

The incidence of beta-2 microglobulin amyloidosis was assessed in two populations of chronic hemodialysis patients. Out of 34 patients who underwent biopsy during orthopedic surgery (33 cases) or autopsy (1 case), 26 had amyloid deposits which fixed anti-beta microglobulin serum. Out of 55 unselected patients treated for over months at the dialysis centre, 14 (25%) had clinical symptoms suggesting amyloidosis and out of 43 patients who had a systematic radiological skeletal survey, 23 (53%) had bone deposits. The plasma beta microglobulin concentrations (about 20 times the normal value) we not significantly different whether or not the patients had histological proven amyloidosis, clinically or radiologically probable amyloidosis, no detectable amyloidosis. However, the duration of hemodialysis was longer in those with proven or highly probable amyloidosis. The finding illustrate the indirect role of elevation of beta-2 microglobulin in the genesis of this pathology and also the necessity of lowering its concentration in order to avoid the long term complications of osteoarticular deposits, the functional consequences of which may be very serious.     

Antibodies to the ADP/ATP carrier, an autoantigen in myocarditis and dilated cardiomyopathy, penetrate into myocardial cells and disturb energy metabolism in vivo

We identified the ADP/ATP carrier, located within the inner mitochondrial membrane, to be an organ- and conformation-specific autoantigen in myocarditis and dilated cardiomyopathy. We also showed that autoantibodies to the ADP/ATP carrier inhibit the nucleotide transport in vitro. Specific binding of the autoantibodies to the carrier was demonstrated by radioimmunoassay and the immunoblot technique; the inhibition of the nucleotide transport was determined by the inhibitor stop method. To establish if these autoantibodies might also affect cardiac energy metabolism in vivo, we measured whether they are capable of penetrating into myocytes and whether subcellular ATP/ADP ratios and phosphorylation potentials of ATP change in hearts of guinea pigs that have been immunized with the isolated ADP/ATP carrier. An intracellular deposition of autoantibodies was observed by direct immunofluorescence and by immunoperoxidase staining on cryosections of the myocardial tissue of animals immunized with the ADP/ATP carrier. Furthermore, binding of autoantibodies to mitochondrial membrane structures was shown by immunoelectron-microscopic methods. The cytosolic and intramitochondrial distribution of adenine nucleotides in stimulated, isolated perfused hearts of guinea pigs immunized with the ADP/ATP carrier was measured by nonaqueous fractionation. Compared with controls performing equal external heart work, the cytosolic ATP decreased in the immunized animals, whereas the mitochondrial ATP increased strongly; ADP concentrations showed an opposite change. Thus, a resultant cytosolic decrease and a marked mitochondrial increase of the ATP/ADP ratio was established. As a consequence, the cytosolic-mitochondrial phosphorylation potential of ATP was diminished. These findings demonstrate that antibodies against intracellular antigens are able to penetrate into living cells, and that autoimmunity to the ADP/ATP carrier may contribute to the pathophysiology of myocarditis and dilated cardiomyopathy by causing an autoantibody-mediated imbalance between intracellular energy delivery and demand.     

Subacute cutaneous lupus erythematosus during PUVA therapy for psoriasis: case report and review of the literature

Lesions typical of subacute cutaneous lupus erythematosus developed in an elderly woman after 6 months of PUVA (8-methoxypsoralen and longwave ultraviolet light) therapy for psoriasis. Pancytopenia, antibodies to double-stranded DNA, and hypocomplementemia developed concurrently with the appearance of the cutaneous lesions. With discontinuation of photochemotherapy, the cutaneous lesions disappeared and the pancytopenia improved.     

Cardiopulmonary interactions in the cardiac patient in the intensive care unit

Critically ill cardiac patients often undergo mechanical ventilation. The interplay between pulmonary and cardiac mechanics is complicated and in many cases may result in impaired transfer of O2 from the atmosphere to the tissues. This article addresses the principles of pulmonary and peripheral gas exchange, as well as the mechanical effects of respiration on the circulation.     

Prospective randomized comparison of mezlocillin therapy alone with combined ampicillin and gentamicin therapy for patients with cholangitis

Forty-six patients with cholangitis were randomized to receive therapy with mezlocillin sodium (24 patients) or a combination of ampicillin sodium--gentamicin sulfate (22 patients). The biliary concentration of mezlocillin was 112 times higher than that of ampicillin and 778 times higher than that of gentamicin. The ratio of the concentration in serum or bile over the minimum inhibitory concentration against aerobic gram-negative bacilli (therapeutic index) was higher for mezlocillin than for either ampicillin or gentamicin. Twenty (83%) of 24 patients were cured following mezlocillin therapy compared with 9 (41%) of 22 patients after ampicillin-gentamicin therapy. The 3 patients with superinfection were in the ampicillin-gentamicin arm of the study. Fewer toxic or adverse effects occurred in association with mezlocillin treatment than with ampicillin-gentamicin treatment. Mezlocillin therapy was more effective, less toxic, and less expensive than treatment with ampicillin and gentamicin for patients with cholangitis.     

On the mechanism of barium induced diastolic depolarisation in isolated ventricular myocytes

Barium can induce spontaneous activity in cardiac non-pacemaker cells. The mechanism of barium induced diastolic depolarisation was studied in isolated ventricular myocytes, using a microelectrode technique. Barium (0.05-0.2 mmol.litre-1) decreased resting potential and caused the membrane potential at the end of the action potential to undershoot the diminished resting value temporarily, thereby inducing diastolic depolarisation. Resting membrane resistance was increased by Ba but at the end of phase 3 repolarisation the resistance temporarily decreased below its steady state diastolic value. In presence of Ba, hyperpolarisation abolished or reversed diastolic depolarisation. At the end of phase 3 repolarisation, membrane resistance was decreased, whether diastolic depolarisation was present, absent or reversed. A high [K]o (15.4 mmol.litre-1) decreased Ba effects on action potential, membrane resistance and diastolic depolarisation. Caesium decreased the Ba induced diastolic depolarisation and the associated increase in membrane resistance, but had little effect on spontaneous activity at depolarised levels. Barium induced an oscillatory potential, with increased membrane resistance. Noradrenaline plus low [Ba]o, and high [Ba]o alone (1-5 mmol.litre-1), can induce spontaneous activity. Thus, in myocardial cells barium induces diastolic depolarisation at polarised levels by a voltage and time dependent block of potassium conductance, which is modulated by action potential voltage changes. However, as [Ba]o is increased, spontaneous activity at a depolarised level may be related to the decay of potassium currents and to oscillatory potentials.     

Breast-saving operations in breast cancer

Breast preserving surgery or conservative surgery consists at present of a combination of a reduced operation--tumorectomy or wedge resection or subcutaneous mastectomy--with adequate radiotherapy whereby a doses of 40-50 Gy is used with or without an additional booster dose of 10 Gy. Recent studies of 5-year- and 10-year-survival rates after conservative management have been shown to be identical with radical operations (Rotter-Halsted, Patey-Auchincloss). In the Departments of Gynecology and Obstetrics of the Universities of Münster and Rostock the partial bilateral subcutaneous mastectomy with lymphadenectomy and irradiation is the preferred method of conservative management for breast cancer. Indications and technique are discussed.