Elective aortocoronary bypass grafting in the elderly

Operative mortality, postoperative morbidity and follow up data were analyzed retrospectively from 122 consecutive patients, over 65 years old undergoing elective aortocoronary bypass grafting for symptomatic relief of angina pectoris at the Plains Health Centre, Regina, Saskatchewan, from January 1980 to December 1985. There were two in-hospital deaths (operative mortality 1.6%). Definite perioperative myocardial infarction occurred in 12 patients (9.8%). The 120 survivors were followed for a mean of 32 months. There were three deaths during follow-up, giving a five-year probability of survival of 93%. Twenty-three clinical events (including deaths) occurred during follow-up, giving a five-year probability of event free survival of 72%. Ninety percent of patients say they are pleased with their operation. Seventy-eight percent are currently angina free. These data illustrate the effectiveness of aortocoronary bypass grafting in low risk elderly patients with symptomatic coronary artery disease.     

Triquetral-lunate arthritis secondary to synostosis

Until recently the problem of painful, symptomatic arthritis of the wrist secondary to congenitally incomplete separation of carpal bones has been infrequently recognized. Five patients with either excessive stress loading or trauma had eight symptomatic wrists with congenitally incomplete separation of the triquetral-lunate joint. Three of these patients had bilateral symptoms. Six of the wrists had been treated by a limited wrist arthrodesis of the triquetral-lunate joint resulting in asymptomatic wrists and improved range of motion. It appears that patients with this congenital condition poorly tolerate stress loading or trauma secondary to deficient intra-articular cartilage formation resulting in a clinical and anatomic state similar to degenerative arthritis. We suggest a limited wrist arthrodesis as definitive treatment for symptomatic congenitally incomplete separation of the triquetral-lunate joint, with possible application in incomplete separation of the other intercarpal joints.     

Challenges in community-based participatory research implementation: experiences in cancer prevention with Pacific Northwest American Indian tribes.

BACKGROUND: Much has been written about community-based participatory research (CBPR) history and principles, but few have addressed challenges in implementation in transcultural situations. The goal of this discussion is to address CBPR implementation issues in cancer prevention research with American Indian tribal communities in the Pacific Northwest. METHOD: Information in this discussion is drawn from qualitative research conducted over a 10-year period in which CBPR was employed in cancer prevention research with Pacific Northwest Indian tribes. CBPR principles provide the framework for the discussion: establishing trusting relationships, assuring participation, sharing power, and communicating. RESULTS: In this work, we found that CBPR is appropriate for use in Pacific Northwest Indian tribal communities and is compatible with cultural values. We also found that there are many challenges. Recommendations are provided on needed institutional and structural changes. CONCLUSIONS: CBPR is an important research approach in addressing cancer prevention health disparities among American Indian tribal communities. Continued effort needs to be directed toward creating systems and structures to support researchers in utilizing this method. Findings are of value to researchers aiming to implement CBPR in Indian communities and to practitioners, policy makers, and administrators who make decisions about CBPR funding and support structures.     

Coats'-type retinitis pigmentosa

Coats'-like changes (i.e., retinal telangiectasia and/or exudative detachment) have been reported in as many as 1.2 to 3.6 percent of patients with retinitis pigmentosa. In severe cases this disorder may progress to total retinal detachment and visual loss in the context of longstanding retinitis pigmentosa. Forty-six cases of Coats'-type retinitis pigmentosa gathered from the literature are reviewed. Historical and epidemiological features, hereditary factors, clinical features, histopathological findings, pathogenesis, differential diagnosis, prognosis and possible treatment are discussed.     

Selective inhibition of T cell proliferation but not expression of effector function by human alveolar macrophages

BACKGROUND: Alveolar macrophages are thought to play an important part in regulating lung immune responses. While it is clear that human alveolar macrophages suppress T cell proliferation in vitro, the mechanisms by which this is achieved are not clear, nor is it known whether alveolar macrophages also inhibit other aspects of T cell function. METHODS: Peripheral blood mononuclear cells were stimulated with phytohaemagglutinin or house dust mite allergen, and cultured with variable numbers of autologous alveolar macrophages obtained by bronchoalveolar lavage from 20 normal subjects. RESULTS: Alveolar macrophages induced a reversible inhibition of T cell proliferation in response to both mitogen and allergen stimulation, with the latter being considerably more susceptible to inhibition. This was achieved via heterogenous mechanisms, involving both soluble factors derived from alveolar macrophages and cell-cell contact. Despite inhibiting proliferation, alveolar macrophages had little or no effect on T cell calcium flux, the characteristic changes in CD3, CD2, CD28 and interleukin-2 (IL-2) receptor expression which accompany normal T cell activation, and IL-2 and interferon gamma secretion. In contrast, alveolar macrophages inhibited the tyrosine phosphorylation of proteins which may be involved in IL-2 receptor-associated signal transduction. CONCLUSIONS: The immunoregulatory properties of alveolar macrophages are relatively selective, allowing T cell activation and cytokine secretion while inhibiting T cell proliferation within the lung.


     

Tick Bites and Lyme Disease in an Endemic Setting: Problematic Use of Serologic Testing and Prophylactic Antibiotic Therapy

Context.— The use of serologic testing to diagnose Lyme disease (LD) is a source of controversy. Expert recommendations also discourage the routine use of antibiotic therapy for prophylaxis of LD following tick bites, but the extent to which physicians in endemic areas have adopted these recommendations is not known. Objective.— To assess the pattern of use of serologic testing and antibiotic therapy for tick bites and LD and associated charges for management in an endemic area. Design.— Active surveillance of patient-physician encounters for tick bites and LD. Setting.— Primary care practices on the Eastern Shore of Maryland. Patients.— Consecutive sample of 232 patients with tick bites, LD (defined by physician diagnosis in medical record), and suspected LD (physician notation of possible, but not definite LD) seen in 1995. Main Outcome Measures.— Serologic testing for LD, test results, antibiotic therapy, and direct costs of management. Results.— Surveillance identified 142 patients (61.2%) with diagnoses of tick bites, 40 patients (17.2%) with LD, and 50 patients (21.6%) with suspected LD. Of the 142 patients seen for tick bites, 95 (67%) underwent serologic testing for LD. Of these, 93 patients had initial negative or equivocal results; 24 (26%) of the 93 had convalescent testing, with 1 seroconversion. Seventy-eight patients (55%) with a diagnosis of tick bite received antibiotic therapy. No patients with tick bite developed clinical LD. Serologic testing for LD was performed for 36 patients (90%) with a diagnosis of LD and 46 patients (92%) with suspected LD. In most cases, antibiotics were prescribed before serologic test results became available. Convalescent testing was not performed for 37 (86%) of the 43 patients with suspected LD who had initial negative or equivocal results. Of these 37 patients, 25 (68%) did not receive antibiotic therapy. Direct charges for treatment of these 232 patients totaled $47595, one third of which was attributable to serologic testing. A total of 32% of direct charges were for patients with tick bites, 48% were for patients with LD, and 20% were for patients with suspected LD. Conclusions.— In this setting, most patients consulting physicians for tick bites received prophylactic antibiotic therapy of unproven efficacy and underwent unnecessary, costly serologic testing. Despite almost universal use in this study, serologic testing for LD did not appear to influence treatment of patients diagnosed as having LD.