Reed B. Bontecou, M.D.—His Role in Civil War Surgery and Medical Photography

This third article on the subject of Civil War injuries and their surgical repair is devoted to Reed B. Bontecou, M.D., a New York surgeon who contributed greatly to the use of photography to document the casualties of the battlefield as seen in the Northern as well as the Southern states. Photographs of the wounded soldiers helped to verify the severity of their injuries, and helped to determine the degree and amount of the post-war pension payments. These photographs were one of the largest sources which were used in the creation of the Otis Archives of the present-day National Museum of Health and Medicine in Washington, D.C. Some of the wounded soldiers' photographs in the Otis Archives demonstrate the use of plastic surgery techniques to repair the wounded face, head and neck, torso, and the extremities by only a handfull of Northern and Confederate surgeons including Gurdon Buck, J.S. Gouley and Henry B. Sands of New York City; H. Culbertson, U.S.V. of Madison, Wisconsin; J. Cooper McKee of Washington, D.C., W.W. Keen, Jr. of Philadelphia; and C.B. Gibson, P.A.C.S. of Richmond; S.H. Stout of Tennessee; and J.B. Bean, a dentist of Chattanooga [4].     

Protein-Losing Enteropathy Following Fontan Palliation

Protein-losing enteropathy (PLE) is a chronic condition involving multiple organ systems that may develop any time following Fontan completion. The pathogenesis of PLE is complex and multifactorial. Chronic venous hypertension, low cardiac output, and abnormal lymphatics may all play a role in the pathogenesis of PLE. Common signs and symptoms include chronic diarrhea, abdominal pain, and ascites. Diagnosis is based on the presence of signs and symptoms in addition to hypoalbuminemia and elevated stool alpha 1 antitrypsin. Early identification and a comprehensive approach to evaluation and treatment are important, as they may affect survival. The initial evaluation should include cardiac catheterization for hemodynamic assessment. Although an evidence base for treatment is lacking, various medical, interventional, and surgical approaches have been described with variable degrees of success. Commonly used therapies include nutritional support, diuretics, subcutaneous unfractionated heparin, budesonide, and sildenafil. Limited data exist for Fontan conversion or takedown. Assessment for heart transplantation should be considered. PLE mortality is high—approximately 50%—but may be mitigated by aggressive investigation and management. The evolving understanding of the role of lymphatics in the pathophysiology of PLE and the emerging role of interventional lymphatic procedures may further improve outcomes in this patient population.     

Nodular Lymphocyte Predominant Hodgkin Lymphoma: Biology,Diagnosis and Treatment

Nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) is an uncommon variant of classical Hodgkin lymphoma. It is characterized histologically by presence of lymphohistiocytic cells which have B-cell phenotype, are positive for CD19, CD20, CD45, CD79a, BOB.1, Oct.2, and negative for CD15 and CD30. Patients often present with early stage of disease and do not have classical B symptoms. The clinical behavior appears to mimic that of an indolent non-Hodgkin lymphoma more than that of classical Hodgkin disease. The purpose of the present report is to define the biology of NLPHL, review its clinical presentation, and summarize the available clinical data regarding treatment.     

The Impact of Cardiac Rehabilitation on Mental and Physical Health in Patients With Atrial Fibrillation: A Matched Case-Control Study

Background

Patients with atrial fibrillation (AF) experience symptom burden, exercise intolerance, weight gain, poor mental health, and diminished quality of life (QoL). Cardiac rehabilitation (CR) is recommended for patients with heart disease, and its benefits are well established, yet clinical guidelines for patients with AF do not include the referral to CR.

Palliative dilation of esophageal carcinoma

The authors' experience with palliative dilation of 46 consecutive patients evaluated for squamous cell carcinoma of the esophagus was retrospectively reviewed. Thirty-nine of 46 patients (85%) underwent dilation in order to palliate symptoms, enable endoscopy and biopsy, or prepare for placement of an esophageal prosthesis. Thirty-two of the 46 patients (70%) were treated with radiation therapy and seven (15%) underwent placement of an esophageal prosthesis. Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing, allowing resumption of a soft or regular diet. Complications were noted in three of the 39 patients dilated (8%). The authors conclude that peroral dilation is a safe, effective, and probably underutilized method of palliation in patients with squamous cell esophageal carcinoma.     

Clinical and electrophysiologic assessment of oral flecainide acetate for recurrent ventricular tachycardia: Evidence for exacerbation of electrical instability

Four patients with recurrent, symptomatic ventricular tachycardia (VT) refractory to conventional antiarrhythmic agents were given flecainide acetate to control arrhythmias. Ventricular stimulation studies were performed in all patients before and 1 to 2 weeks after initiation of oral flecainide therapy. Before flecainide, all patients had easily inducible VT that was morphologically identical to their spontaneously occurring arrhythmia. Flecainide increased the mean PR interval (from 0.17 to 0.23 second), mean QRS duration (from 0.08 to 0.12 second) and mean ventricular effective refractory period (from 235 to 270 ms). Mean corrected QT interval did not change (0.51 second).In 2 patients, VT could not be induced during follow-up stimulation studies. One patient has been treated successfully for 10 months, with no clinically apparent episodes of VT. One patient had recurrent nonsustained VT and was withdrawn from the study as a treatment failure after 6 months of therapy. Two patients had inducible, polymorphous VT that degenerated into ventricular fibrillation that required 2 countershocks before the successful restoration of sinus rhythm. One of these patients had VT stimulation by atrial pacing at a cycle length of 320 ms in the postflecainide electrophysiologic study. VT was not inducible by atrial pacing during this patient's preflecainide study.Thus, sustained oral flecainide administration may precipitate serious electrical instability in susceptible patients, and ventricular stimulation studies and other clinical variables may be useful in selecting patients with recurrent VT who may benefit or may be endangered by oral flecainide therapy.     

Specific binding of 1,25 dihydroxyvitamin D3 in lymphocytes

We examined ten cellular or tissue sources of lymphocytes for specific binding of 1,25(OH)₂D₃, the hormonally active form of vitamin D₃. A specific-binding protein was found in three of these sources. Scatchard analysis of cytosol from a follicular lymphoma cell line revealed binding sites with a Kd of 7.0 × 10^?11 and a receptor concentration of 6.6 fmol/mg protein. Sucrose density centrifugation of ³H-1,25(OH)₂D₃ labeled cytosol showed a 3.75 peak which was absent in cytosols incubated with excess nonradioactive 1,25(OH)₂D₃. The relative amounts of vitamin D₃ metabolites required to displace 50% of the specifically bound ³H-1,25(OH)₂D₃ were 1,25(OH)₂D₃: 1,24,25(OH)₃D₃: 25(OH)D₃: 24,25(OH)₂D₃ = 1: 180: 1000: 2700. Excess vitamin D₃, cortisol, and estradiol failed to displace ³H-1,25(OH)₂D₃. Scatchard analysis of spleen cytosol from a patient with prolymphocytic transformation of chronic lymphocytic leukemia demonstrated a binding protein with a Kd of 1.2 × 10^?10 and a receptor concentration of 0.2 fmol/mg protein. DNA cellulose binding confirmed the presence of the specific-binding protein in this cytosol. Specific binding of ³H-1,25(OH)₂D₃ was also quantitated in a cell line from a patient with Burkitt's lymphoma with a Kd of 0.3 × 10^?10 and a receptor concentration of 29.6 fmol/mg protein. No specific binding of ³H-1,25(OH)₂D₃ was observed in lymphocytes from seven other malignant and nonmalignant sources. These results are the first to demonstrate a specific-binding protein for 1,25(OH₂D₃ in lymphocytes from tissue and from these specific cell lines. The presence of this protein in some lymphocytes but not others may reflect the state of activation of the lymphocytes.     

Hemiagenesis of the thyroid gland.

Three patients with hemiagenesis of the typhoid gland are described. One was clinically euthyroid, whereas the other two were more unusual in that one had coincident Graves' disease with thyrotoxicosis, and one had primary myxodema. In all three cases diagnosis of hemiagenesis was established by the administration of thyroid-stimulating hormone (TSH). The literature on hemiagenetic thyroid glands with and without associated thyroid disease is reviewed. Although the anomaly is uncommon, awareness and recogniton of its existence may clarify an otherwise puzzling clinical thyroid evaluation, and thus possible avert an unnecessary surgical procedure.     

Portal and peripheral vein concentrations of insulin and glucagon after arginine infusion in morbidly obese subjects

Five morbidly obese subjects with fasting normoglycemia underwent catheterization of portal and peripheral veins immediately prior to jejunoileal bypass surgery. Levels of immunoreactive insulin (IRI), immunoreactive glucagon (IRG), and glucose were determined in simultaneously obtained serum samples before and after infusion of arginine. Portal levels exceeded peripheral levels by at least 50% with IRI and by 30%–40% with IRG. These results were similar to those reported in nonobese subjects and show that in morbid obesity as well as in nonobese states, peripheral insulin to glucagon molar ratios ($\text{I}\text{G}$) underestimate portal $\text{I}\text{G}$. Although hepatic extraction was not specifically measured, the data suggest that the peripheral levels of insulin and glucagon reported in morbid obesity result from alterations in secretion and not altered extraction.