Congo red-negative amyloidosis-like glomerulopathy

Three cases of amyloidosis-like glomerulopathy are presented in which renal amyloidosis was initially diagnosed on the basis of ultrastructural findings, despite negative Congo red staining. The histologic and immunofluorescence findings and, on careful examination, ultrastructural features of this amyloidosis-like glomerulopathy all serve to distinguish it from true amyloidosis. The clinical behavior suggests that it is a primary glomerulopathy since, with time, no other systems become involved.     

Hospital-wide surveillance: Perspective for the practitioner

Hospitals with limited resources need to develop priorities and might consider directing their surveillance efforts in the critical care areas. Once surveillance in these areas has been completed, the practitioner can focus attention on other areas of the hospital, including in-service activities. The preliminary report of the CDC's study of the efficacy of nosocomial infection control (SENIC study) showed a direct correlation between the level of in-service activities and subsequent infection rates. In conclusion, goals for a cost effective surveillance system program should reflect (1) priority areas for surveillance, (2) decision as to what information needs reporting, and (3) effective utilization of data to direct preventive efforts and outbreak investigation.     

Colonoscopy: an essential monitoring technique after resection of colorectal cancer

A pilot study was undertaken to determine the usefulness of colonoscopy in the postoperative follow-up of patients with colorectal cancer. Of 56 patients, 9 (17 percent) had positive intraluminal examinations, including one recurrent cancer and three large polyps (greater than 1 cm) despite normal barium enema films. Twenty percent had negative colonoscopic findings which ruled out suspicious lesions on roentgenograms. More than one third had alterations in therapy as a result of colonoscopic examination. Colonoscopy is a useful and fruitful diagnostic aid in the follow-up of colon cancer. It should be used early in the postoperative period and added at rational intervals in long-term surveillance. It appears to complement other accepted methods of detecting recurrence.     

Double-blind, placebo-controlled trial of propranolol given once, twice and four times daily in stable angina pectoris: a multicenter study using serial exercise testing

To determine if propranolol given twice daily (b.i.d.) or once daily (q.d.) was as effective as 4 times daily (q.i.d.) for treatment of stable angina pectoris, 78 patients with exercise-induced ST depression of 1.5 mm were randomized to q.i.d., b.i.d., q.d. and placebo groups. All patients received 5 tablets per day, and propranolol groups received 80, 160 and 320 mg/day on successive weeks. At weekly visits, patients underwent treadmill exercise testing before the 8:00 AM dose and at 2 and 9 hours afterward. Exercise duration (seconds) was significantly improved at the final visit compared with baseline by b.i.d. (120 +/- 36 [mean +/-] standard error of the mean p less than 0.001 n = 18) and q.i.d. (100 +/- 37, p less than 0.01; n = 17) regimens, but not by the q.d. (30 +/- 33; n = 18) and placebo regimens (27 +/- 37; n = 17). There was a significant decrease from baseline in the magnitude of ST depression at the final visit, measured at maximal common exercise duration in b.i.d. (-0.96 +/- 0.20 mm, p less than 0.001), q.i.d. (-0.84 +/- 0.20 mm, p less than 0.01) and q.d. (-0.58 +/- 0.18 mm, p less than 0.05) groups, but not in the placebo group (0.03 +/- 0.2 mm). Hourly heart rate by Holter was reduced in all 3 propranolol groups; however, the mean serum propranolol level was significantly lower just before the first dose with q.d. group (56 +/- 20 ng/ml) compared with b.i.d. and q.i.d. groups (146 +/- 22 and 119 +/- 28 ng/ml) with 320 mg/day (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Immune lesions of central noradrenergic neurons produced by antibodies to dopamine-β-hydroxylase

(1) Intraventricular injection of antibodies to dopamine-beta-hydroxylase (DBH) caused degeneration of central noradrenergic nerve terminals in rats and guinea-pigs. In rats it was necessary to infuse exogenous complement in the form of guinea-pig serum together with the anti-DBH, whereas in guinea-pigs the anti-DBH was effective on its own. Control animals were infused with equivalent amounts of non-immune serum and complement and showed no signs of degeneration other than in the region of the needle tract. (2) There was a loss of varicosities in most terminal fields of the noradrenergic projections and swollen distorted axons were seen in both ascending and descending noradrenergic pathways. Noradrenergic cell bodies in the locus coeruleus and subcoeruleus appeared unaffected. No histochemical changes were observed in dopaminergic neurons. (3) The ultrastructural changes in degenerating axons that were first identifided by fluorescence histochemistry included swelling, vacuolation, accumulation of dense cored vesicles, lysosome-like bodies and smooth membranous sacs. The surrounding neuropil appeared normal. (4) There was a significant depletion of noradrenaline in all regions of the rat brain ranging from 20% in the hypothalamus to 80% in the neocortex. Dopamine concentrations were unaffected. (5) These observations provide a new approach to the production of selective lesions in specific neurotransmitter pathways that could be extended to non-adrenergic neurones. They may also be useful as a model for the study of autoimmune diseases of the nervous system.     

Effects of percutaneous transluminal angioplasty on renal plasma flow

Percutaneous transluminal angioplasty is being used with increasing frequency for the treatment of renal artery stenosis. Several noninvasive techniques that utilize radioactive tracers have been used for monitoring the effects of angioplasty and progression of disease. Forty-one patients were studied before and after renal angioplasty by using renograms and fractionated measurements of effect renal plasma flow. Although there were striking examples of improvement in effective renal plasma flow following angioplasty, this was not a consistent finding. There was a tendency for effective renal plasma flow to revert to the baseline level on follow-up studies. Cure of hypertension was more likely in patients without renal insufficiency and in patients with shorter periods of sustained hypertension. Fractionated effective renal plasma flow studies did not reliably differentiate patients who were cured from those who were improved nor were we able to delineate clearly those requiring repeat dilatation. Nevertheless, this technique is useful for noninvasively measuring fractionated renal function in the immediate postoperative or postdilatation recovery period and for detecting the difference between occlusion of the renal artery and transient renal insufficiency due to contrast material. Also, long-term measurement of fractionated function has value in following potential progression of the basic disease process.     

Two-dimensional echocardiographic measurement of left ventricular ejection fraction: Prospective analysis of what constitutes an adequate determination

2DE is increasingly being used to determine LVEF. There remain, however, important questions about the 2DE determination of EF: (1) which 2DE formulae correlate best with contrast ventriculography; (2) how often can a particular formula be applied to a large group of patients; and (3) what effect does 2DE quality or the presence of segmental wall motion abnormalities have on the accuracy of echo determined EF? To answer these questions, we prospectively determined the 2DE EF utilizing 10 differen formulae in 65 consecutive patients undergoing contrast ventriculogram within the following 24 hours. We also sought to examine the ability of trained observers to estimate EF from 2DE. The 2DE EF formulae that utilized biplane areas were generally more accurate than single-plane area or diameter only formulae, but were obtainable in fewer patients. The biplane Simpson's rule yielded a correlation with ventriculogram of r = 0.89, but was available in only 34 patients. While the single-plane formulae were slightly less accurate, they were measured in more patients; ellipsoid single-plane apical four-chamber r = 0.80, N = 56, and short ellipse r = 0.86, N = 47. The measured EF in patients with akinetic segments yielded a greater standard error of the mean, although correlations remained adequate when compared to the normal patient population. The EF from patients with poor quality as compared to good quality echo studies had a slightly greater standard error, but correlations were little affected. Thus biplane formulae for calculating EF yield better correlations, but are available from fewer patients than single-plane formulae. An estimate of EF was sufficiently accurate for most clinical situations and was available in 98% of the patients. The presence of abnormal wall motion or a poor quality 2DE study increased the standard error slightly, but had little effect on correlation with contrast ventriculogram.     

Acute renal failure in the cardiovascular surgical patient

Acute renal failure is a known complication of cardiovascular surgery and is associated with a high mortality. Therapy should be aimed at prevention of oliguric renal failure, or at least its conversion to nonoliguric renal failure. Once renal failure is established, early dialysis with nutritional support probably gives the best chance for survival.