ECHOCARDIOGRAPHY, Issue 7 2003
Miquel Gómez Pérez M.D.
Cardiac involvement in vasculitis syndromes is uncommon. We describe a 50-year-old male who presented with progressive dyspnea and myalgies. Echocardiogram revealed significant thickening of aortic root, aortic cusps, and anterior mitral valve leaflet, with severe aortic regurgitation that required aortic valve replacement. Furthermore, this patient suffered progressive atrioventricular block that needed implantation of a pacemaker. The study performed disclosed the presence of necrotizing vasculitis positive for perinuclear antineutrophil cytoplasmic antibody. (ECHOCARDIOGRAPHY, Volume 20, October 2003) [source]

Adrenal Insufficiency in Critically Ill Emergency Department Patients: A Taiwan Preliminary Study

ACADEMIC EMERGENCY MEDICINE, Issue 7 2001
Shy-Shin Chang MD
Objective: Unrecognized adrenal insufficiency can have serious consequences in critically ill emergency department (ED) patients. This prospective pilot study of adrenal function in patients with severe illness was undertaken to determine the prevalence of adrenal dysfunction and any relation to prior herbal drug use. Methods: In a high-volume urban tertiary care ED, adult patients with sepsis or acute myocardial infarction (AMI) were eligible for the study. Over a two-month period, a convenience sample was enrolled by the authors on arrival to the ED. Inclusion criteria were systemic inflammatory response syndrome (SIRS) criteria plus evidence of at least one organ dysfunction or cardiac marker plus electrocardiogram-proven AMI. Exclusion criteria included known corticosteroid use. Serum cortisol was measured on arrival and for those patients with a level of <15 ,g/dL (<414 nmol/L), an adrenocorticotropic hormone (ACTH) stimulation test was performed. Results: Of the 30 enrolled patients, 23 (77%) were suffering from severe sepsis and the other seven (23%) had an AMI. Thirteen of the 30 patients (43%; 95% CI = 25% to 65%) had serum cortisol levels of <15 ,g/dL, consistent with adrenal insufficiency, nine with severe sepsis and four with an AMI. Eight (62%; 95% CI = 32% to 86%) of the 13 patients with low cortisol levels reported using herbal medications, while only two (12%; 95% CI = 1% to 36%) of the 17 with normal cortisol levels reported taking herb drugs (p = 0.01). Only two (15%; 95% CI = 2% to 45%) of the patients with low cortisol levels failed their corticotropin stimulation test, suggestive of true adrenocortical insufficiency. Both reported using herbal preparations. Conclusions: These results indicate that adrenal dysfunction is common among a group of critically ill patients seen in this Taiwanese ED. Moreover, the use of herbal drugs was high in the patients with low serum cortisols. Further studies are required to both confirm these findings and clarify whether a number of herbal medications contain corticosteroids. [source]

Vitamin D Insufficiency and Acute Care in Geriatric Inpatients

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2009
Aurélien Sutra del Galy MD
No abstract is available for this article. [source]

Estimation of Glomerular Filtration Rate in Older Patients with Chronic Renal Insufficiency: Is the Modification of Diet in Renal Disease Formula an Improvement?

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2003
Edmund J. Lamb PhD
OBJECTIVES: To evaluate a new formula for glomerular filtration rate (GFR), derived from the Modification of Diet in Renal Disease (MDRD) study in older people. DESIGN: An observational study of the performance of the MDRD formula compared with other formulae and creatinine clearance (ClCr) as measures of the GFR. SETTING: Volunteers were recruited via outpatient clinics. PARTICIPANTS: Fifty-two patients (27 men, 25 women: mean age 80, range 69,92) with a variety of medical diagnoses. Mean GFR was 53.3 mL/min/1.73 m2 (range 15.9,100.2). Exclusion criteria included renal replacement therapy/renal transplantation and cognitive impairment. MEASUREMENTS:51Chromium ethylenediaminetetraacetic acid (51Cr EDTA) was used as the reference method against which the formulaic estimates of GFR were compared using bias plot and regression analyses. RESULTS: The MDRD and Cockcroft and Gault formulae (both coefficient of determination (R2) = 0.84) gave the best fit with GFR, followed by the Jelliffe formula (R2 = 0.81), ClCr (R2 = 0.73) and the Baracskay formula (R2 = 0.56). ClCr (,1.2%) demonstrated minimal bias compared with the MDRD (8.0%) and Cockcroft and Gault (,10.4%) formulae. However, imprecision compared with 51Cr EDTA was lowest for the Cockcroft and Gault formula, with 50% of estimates lying between ,9.5 and ,0.5 mL/min/1.73 m2 of measured 51Cr EDTA clearance. This compares with ,6.7 and 10.1 mL/min/1.73 m2 for ClCr and 0.0 and 12.7 mL/min/1.73 m2 for the MDRD formula. CONCLUSION: Calculated estimates of GFR are an improvement over ClCr estimation. On balance, the MDRD formula does not improve the estimate of GFR compared with the Cockcroft and Gault formula in older Caucasian patients with chronic renal insufficiency. [source]

Quadricuspid Aortic Valve With Aortic Insufficiency: Case Report and Review of the Literature

JOURNAL OF CARDIAC SURGERY, Issue 3 2007
Natalie F. Holt M.D.
With improvements in echocardiographic imaging, the diagnosis of QAV is likely to be made more reliably in the future and should prompt close clinical follow-up given the frequent association of this lesion with valvular insufficiency. [source]

Involvement of Jugular Valve Insufficiency in Cerebral Venous Air Embolism

JOURNAL OF NEUROIMAGING, Issue 3 2007
Max Nedelmann MD
ABSTRACT Background. Cerebral venous air entrapment is a rare finding on cranial computed tomography (CT) scan. Peripheral air embolism is discussed as a potential cause. However, the mechanism of retrograde passage through internal jugular valves and veins is unclear. Case Report. The case of a patient is reported, who had air entrapment in the left cavernous sinus. Prior to CT scanning, a peripheral intravenous line had been placed. Ultrasound revealed excessive insufficiency of the left internal jugular valve. To further study the mechanism of embolism, an echo contrast agent was injected into the cubital vein. A Valsalva maneuver resulted in retrograde transition of microbubbles across the insufficient valve. Valvular function on the unaffected right side was intact. Conclusions. This case report gives insight into the mechanism of cerebral venous air embolism. This is the firstcase describing jugular valve insufficiency as the missing link between peripheral air embolism and cerebral venous air entrapment. [source]

The Treatment of Acute Adrenocortical Insufficiency in the Dog

JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 1 2001
DACVECC, DACVIM, Michael Schaer DVM
Summary Acute hypoadrenocorticism in the dog is a true medical emergency that requires a prompt and accurate diagnosis and appropriate treatment in order to provide for the most optimal outcome. Because the signs of adrenal insufficiency mimic those caused by other more common clinical conditions such as renal failure, intoxications, and various gastrointestinal disorders, it behooves the emergency clinician to always include this condition in the list of differential diagnoses. This paper will review the main elements of this hypoendocrinopathy in order to provide the emergency clinician with the essentials that will be required for appropriate diagnosis and treatment. J Vet emerg Crit Care 2001; 11(1):7,14 [source]

Breed Associations for Canine Exocrine Pancreatic Insufficiency

JOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 2 2007
Daniel J. Batchelor
Background:Knowledge of breed associations is valuable to clinicians and researchers investigating diseases with a genetic basis. Hypothesis:Among symptomatic dogs tested for exocrine pancreatic insufficiency (EPI) by canine trypsin-like immunoreactivity (cTLI) assay, EPI is common in certain breeds and rare in others. Some breeds may be overrepresented or underrepresented in the population of dogs with EPI. Pathogenesis of EPI may be different among breeds. Animals:Client-owned dogs with clinical signs, tested for EPI by radioimmunoassay of serum cTLI, were used. Methods:In this retrospective study, results of 13,069 cTLI assays were reviewed. Results:An association with EPI was found in Chows, Cavalier King Charles Spaniels (CKCS), Rough-Coated Collies (RCC), and German Shepherd Dogs (GSD) (all P < .001). Chows (median, 16 months) were younger at diagnosis than CKCS (median, 72 months, P < .001), but not significantly different from GSD (median, 36 months, P= .10) or RCC (median, 36 months, P= .16). GSD (P < .001) and RCC (P= .015) were younger at diagnosis than CKCS. Boxers (P < .001), Golden Retrievers (P < .001), Labrador Retrievers (P < .001), Rottweilers (P= .022), and Weimaraners (P= .002) were underrepresented in the population with EPI. Conclusions and Clinical Implications: An association with EPI in Chows has not previously been reported. In breeds with early-onset EPI, immune-mediated mechanisms are possible or the disease may be congenital. When EPI manifests later, as in CKCS, pathogenesis is likely different (eg, secondary to chronic pancreatitis). Underrepresentation of certain breeds among dogs with EPI has not previously been recognized and may imply the existence of breed-specific mechanisms that protect pancreatic tissue from injury. [source]

Microcirculatory Dysfunction in Chronic Venous Insufficiency (CVI)

MICROCIRCULATION, Issue S1 2000
MICHAEL JÜNGER
ABSTRACT The elevated ambulatory pressure in the peripheral venous system of chronic venous insufficiency (CVI) patients manifests itself not only in the form of disturbed macrocirculation but also and particularly in microangiopathic changes. For this reason, it is closely correlated with trophic disorders of the skin and can ultimately lead to ulceration. Using microcirculation research techniques, we are able to provide clear evidence of a typical microangiopathy in chronic venous insufficiency. Fifty CVI patients in Widmer stages I, II, and III were examined with fluorescence video microscopy, intravital video capillaroscopy, transcutaneous oxygen partial pressure measurement, TcpO2 and laser Doppler flowmetry. The effects of compression therapy with individually fitted compression stockings on capillary morphology were studied over a period of 4 weeks in 20 CVI patients in Widmer stages I and II. The capillary pressure was measured during simulated muscle contraction using a servo-null micropressure system. We periodically drew blood from the dorsalis pedis vein and a brachial vein of 11 healthy test persons and 8 patients with stage III CVI during experimental venous hypertension in order to evaluate the expression pattern of leukocyte adhesion molecules involved in inflammation: LFA-1 (CD11a), Mac-1 (CD11b), p150,95 (CD11c), CD18, VLA-4 (CD49d), and L-selectin (CD62L). In the same patients, we used immunohistochemical methods to examine clinically unaffected skin and the skin near an ulcer, focusing on the adhesion molecules ICAM-1, VCAM-1, and E-selectin. The microangiopathic changes observed with worsening clinical symptoms include a decrease in the number of capillaries, glomerulus-like changes in capillary morphology, a drop in the oxygen content (tcpO2) of the skin, increased permeability of the capillaries to low-molecular-weight substances, increased laser Doppler flux reflecting elevated subcutaneous flow, and diminished vascular reserve. These microangiopathic changes worsen in linear proportion to the clinical severity of chronic venous insufficiency. In patients with venous ulcerations, the baseline expression of LFA-1 and VLA-4 on lymphocytes, Mac-1 expression on the myeloid cell line, and L-selectin expression on all three cell lines was not significantly different from that in healthy controls. During orthostatic stress, there was a significant reduction in the expression of L-selectin in blood cells collected at foot level in the controls (p = 0.002), but not in the patients. Clinical improvement by compression therapy was accompanied by an increase in the number of nutritive capillaries, while the diameter of the capillaries and the dermal papillae was reduced. When ulcers healed in a short period (<6 weeks), we observed a concomitant increase in the number of capillaries (p < 0.05). Microangiopathy appears before trophic disorders of the skin develop. Even trophically normal skin areas may have dilated nutritive capillaries, an early sign of disturbed skin perfusion. These changes represent a plausible explanation for the development and to recurrency tendency of venous ulcers. The reduced expression of lymphocytic L-selectin in healthy controls during the orthostatic stress test may be an indication that the cells are activated by venous stasis. Clinically effective therapeutic measures improve the impaired microcirculation of the skin in the ankle area. [source]

Experimental Models To Investigate Inflammatory Processes in Chronic Venous Insufficiency

MICROCIRCULATION, Issue S1 2000
RONALD J. KORTHUIS
ABSTRACT Chronic venous insufficiency (CVI) is characterized by leukocyte adhesion and infiltration, venous hypertension and dilatation, and valvular dysfunction. The fact that activated white cells can direct a powerful cytotoxic arsenal at parenchymal cells following their extravasation into the tissues led to the original proposal that leukocytes may play a causative role in the pathogenesis of venous disease. A large body of subsequent work indicates that white blood cells are indeed activated in CVI. However, identification of the factors responsible for initiating leukosequestration and activation in such disorders and determination of whether these activated cells then contribute to the progression of venous disease have been hampered by the lack of appropriate animal models that accurately mimic the human condition. Tantalizing evidence suggesting that cyclical periods of ischemia and reperfusion (I/R) may occur in diseased regions of the skin is beginning to accumulate. As is the case with CVI, leukocyte infiltration is a prominent feature in I/R and activated neutrophils play a causative role in the reperfusion component of tissue injury via the targeted release of reactive oxygen metabolites and hydrolytic enzymes. In light of these considerations, many investigators have suggested that examining the mechanisms of I/R injury in skin and skeletal muscle, where ischemia is produced by arterial occlusion, may provide a relevant model for studying the pathogenesis of CVI. Others have suggested that venous occlusion may represent a more appropriate model, as this approach also produces the venous hypertension that is characteristic of the disease. The purpose of this review is to summarize the evidence pointing to the involvement of I/R and venous hypertension as causative factors in CVI-induced leukocyte recruitment. In addition, we will describe the evidence in favor of the view that white blood cells contribute to the pathogenesis of CVI. Finally, we will describe several different experimental models that have been used to examine the role of I/R-induced microvascular dysfunction as it may pertain to the development of CVI, together with a discussion of the relative advantages and limitations of the various models. [source]

Response to Cardiac Resynchronization Therapy in Patients with Heart Failure and Renal Insufficiency

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010
EVAN C. ADELSTEIN M.D.
Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF) patients, partly because renal and cardiac dysfunction are intertwined, yet few cardiac resynchronization therapy (CRT) studies have examined patients with moderate-to-severe RI. Methods: We analyzed 787 CRT-defibrillator (CRT-D) recipients with a glomerular filtration rate (GFR) measured prior to implant. Patients were grouped by GFR (in mL/min/1.73 m2): ,60 (n = 376), 30,59 (n = 347), and <30 (n = 64). Overall survival, changes in left ventricular (LV) ejection fraction and LV end-systolic diameter, and GFR change at 3,6 months were compared among CRT-D groups and with a control cohort (n = 88), also stratified by GFR, in whom LV lead implant was unsuccessful and a standard defibrillator (SD) was placed. All patients met clinical criteria for CRT-D. Results: Among CRT-D recipients, overall survival improved incrementally with higher baseline GFR (for each 10 mL/min/1.73 m2 increase, corrected hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.13,1.30, P < 0.0001). Survival among SD and CRT-D patients within GFR < 30 and GFR , 60 groups was similar, whereas CRT-D recipients with GFR 30,59 had significantly better survival compared to SD counterparts (HR 2.23, 95% CI 1.34,3.70; P = 0.002). This survival benefit was associated with improved renal and cardiac function. CRT recipients with GFR , 60 derived significant echocardiographic benefit but experienced a GFR decline, whereas those with GFR < 30 had no echocardiographic benefit but did improve GFR. Conclusions: CRT may provide the largest survival benefit in HF patients with moderate RI, perhaps by improving GFR and LV function. Severe baseline RI predicts poor survival and limited echocardiographic improvement despite a modest GFR increase, such that CRT may not benefit those with GFR < 30 mL/min/1.73 m2. CRT recipients with normal renal function derive echocardiographic benefit but no overall survival advantage. (PACE 2010; 850,859) [source]

A Case of Human Intramuscular Adrenal Gland Transplantation as a Cure for Chronic Adrenal Insufficiency

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 2 2010
E. Grodstein
Intramuscular endocrine gland transplantation has been well described as it pertains to parathyroid autotransplantation; however, transplantation of the adrenal gland is less well characterized. While adrenal autotransplantation in the setting of Cushing's disease has been described, intramuscular adrenal allotransplantation as a cure for adrenal insufficiency to our knowledge has not been previously carried out. Current treatment for adrenal insufficiency leaves patients without diurnal variation in cortisol release and susceptible to the detrimental effects of chronic hypercortisolism. We describe here the case of a 5-year-old girl with renal failure who had adrenal insufficiency following fulminant meningococcemia that led to requirements for both stress-dose steroid and mineralocorticoid replacement. Ten months after the onset of her disease, she received a simultaneous renal and adrenal gland transplant from her mother. The adrenal gland allograft was morselized into 1 mm3 segments and implanted into three 2 cm pockets created in her rectus abdominis muscle. Three years after surgery, her allograft remains fully functional, responding well to adrenocorticotropin hormone stimulation and the patient does not require any steroid or mineralcorticoid supplementation. We believe this case represents the first description of successful functional intramuscular adrenal allograft transplantation with long-term follow up as a cure for adrenal insufficiency. [source]

Diagnosis of Acute Mitral Valve Insufficiency Using Emergency Bedside Echocardiography

ACADEMIC EMERGENCY MEDICINE, Issue 7 2009
Jeremy Sautner MD
First page of article [source]

Molecular Adsorbents Recirculating System Dialysis for Liver Insufficiency and Sepsis Following Right Ventricular Assist Device after Cardiac Surgery

ARTIFICIAL ORGANS, Issue 8 2004
Otrud Vargas Hein
Abstract:, We report a case of right heart failure (RHF) and sepsis with liver insufficiency in a 70-year-old patient after coronary artery bypass graft surgery. Three hours after surgery the patient suddenly developed therapy refractory cardiac arrest caused by RHF. He had to have emergency surgery, under which the graft to the right coronary artery was revised and a right ventricular assist device was implanted. Heart function recovered and the assist device was explanted on day 1 after surgery. Thoracic closure was performed on day 5 after surgery. The patient went into septic shock on day 11. Liver dysfunction developed postoperatively and worsened the course of sepsis. Therefore, MARS (molecular adsorbents recirculating system) dialysis was performed once on day 20 after surgery. Liver function improved after MARS therapy and the patient recovered from sepsis. On day 46 the patient was transferred from the ICU of another hospital to one of the peripheral wards, to be finally discharged on day 67. [source]

Partial growth hormone deficiency in adults; should we be looking for it?

CLINICAL ENDOCRINOLOGY, Issue 4 2010
Stephen M. Shalet
Summary Quantitatively, GH secretion exists as a continuum in states ranging from good health through to hypopituitarism. Currently, GH replacement is considered only for adults designated as being severely GH deficient (GHD). In clinical practice the gold standard, on which the biochemical diagnosis of severe GHD is based, centres on the presence of two or more additional anterior pituitary hormone deficits. Cohorts of adults with partial GHD (Growth Hormone Insufficiency [GHI]) have been reported with adverse body composition changes, dyslipidaemia, insulin resistance, altered cardiac performance and increased carotid intima-media thickness. The diagnosis of GHI in an individual patient, however, is extremely difficult because such patients rarely exhibit additional anterior pituitary hormone deficits, and the levels of GH-dependent proteins, including IGF-I, are normal in the majority. Currently, GH replacement therapy should only be considered in a patient characterized as GHI by dynamic GH testing in whom there is a plausible cause for hypopituitarism and in whom the IGF-I level is pathologically low. [source]

Nonvisible Insufficient Subcutaneous Reticular Venous Plexus Can Be Observed through the Skin Using a New Illumination Method

DERMATOLOGIC SURGERY, Issue 2010
LUIS LOPEZ BUSTOS MD
BACKGROUND Insufficient subcutaneous reticular venous plexus (ISRVP) is an overlooked disease because the human eye cannot see many of the insufficient veins. OBJECTIVE To present a total reticular vision (TRV) method that exposes nonvisible ISRVP to normal vision. METHOD & MATERIALS TRV used visual-spectrum white and red light of 700 nm and infrared light of 15 to 850 nm from an ultradigital viewer camera. We studied 124 asymptomatic subjects from the general population without visible ISRVP. Another six patients with ISRVP without other venous pathology were compared with six healthy controls, Very low pressure was applied to the proximal thigh, and minimal volume increments on the medial malleolus were photoplethysmographically registered to validate subcutaneous venous reflux. RESULTS Total reticular vision exposed ISRVP on the lower extremities in 72 of 124 subjects (58%), with observed damaged veins corresponding to more than 90% of nonvisible and 5% of visible portions of ISRVP. Subcutaneous reflux was registered only in patients with ISRVP. CONCLUSION Total reticular vision exposed more than 90% of nonvisible ISRVP, a new pathology, allowing for the study of its relationship with other superficial venous insufficiencies. The authors have indicated no significant interest with commercial supporters. [source]

Vitamin D and calcium deficits predispose for multiple chronic diseases

EUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 5 2005
M. Peterlik
Abstract There is evidence from both observational studies and clinical trials that calcium malnutrition and hypovitaminosis D are predisposing conditions for various common chronic diseases. In addition to skeletal disorders, calcium and vitamin D deficits increase the risk of malignancies, particularly of colon, breast and prostate gland, of chronic inflammatory and autoimmune diseases (e.g. insulin-dependent diabetes mellitus, inflammatory bowel disease, multiple sclerosis), as well as of metabolic disorders (metabolic syndrome, hypertension). The aim of the present review was to provide improved understanding of the molecular and cellular processes by which deficits in calcium and vitamin D cause specific changes in cell and organ functions and thereby increase the risk for chronic diseases of different aetiology. 1,25-dihydroxyvitamin D3 and extracellular Ca++ are both key regulators of proliferation, differentiation and function at the cellular level. However, the efficiency of vitamin D receptor-mediated intracellular signalling is limited by the negative effects of hypovitaminosis D on extrarenal 25-hydroxyvitamin D-1,-hydroxylase activity and thus on the production of 1,25-dihydroxyvitamin D3. Calcium malnutrition eventually causes a decrease in calcium concentration in extracellular fluid compartments, resulting in organ-specific modulation of calcium-sensing receptor activity. Hence, attenuation of signal transduction from the ligand-activated vitamin D receptor and calcium-sensing receptor seems to be the prime mechanism by which calcium and vitamin D insufficiencies cause perturbation of cellular functions in bone, kidney, intestine, mammary and prostate glands, endocrine pancreas, vascular endothelium, and, importantly, in the immune system. The wide range of diseases associated with deficits in calcium and vitamin D in combination with the high prevalence of these conditions represents a special challenge for preventive medicine. [source]

Dextropropoxyphene withdrawal from a French university hospital: impact on analgesic drug consumption

FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 2 2009
Sabine Gaubert
Abstract Dextropropoxyphene is a weak opioid analgesic, widely used as a step 2 analgesic (according to WHO classification) in combination with peripheral analgesics, mainly paracetamol. Recent data have underlined its poor analgesic efficacy (in comparison with paracetamol), risks of serious adverse drug reactions (i.e. hepatic reactions, hallucinations, abuse, withdrawal symptoms, hypoglycaemia), possible lethality after overdose, its risk of accumulation in patients with renal failure or in elderly people and some pharmacokinetic insufficiencies (i.e. different half-lives for dextropropoxyphene and paracetamol). Taking into account these data, the drug committee of the Toulouse University Hospital (France) decided to withdraw dextropropoxyphene from the hospital formulary since 1 June 2005. The aim of our study was to investigate the consequences of this withdrawal by comparing use of analgesic drugs in Toulouse University Hospital before (2004) and after (2006) dextropropoxyphene withdrawal (using defined daily dose for 1000 hospitalization-days as the unit measure). Before withdrawal, dextropropoxyphene (in combination with paracetamol) was the second most used analgesic drug after paracetamol alone. After dextropropoxyphene withdrawal, total consumption of analgesic drugs decreased by 4.6% (2006 vs. 2004). There was a 28% decrease in consumption of step 2 analgesics [with an increase in oral tramadol and a slight decrease in codeine (in combination with paracetamol)]. During the same period, step 1 analgesic consumption increased by 11% (mainly paracetamol) and that of step 3 analgesics slightly decreased (,8%). These results show that dextropropoxyphene withdrawal was not associated with a marked switch in prescriptions towards other analgesic drugs. This paper underlines the interest of a hospital-based drug committee to promote rational drug use. Finally, the present data allow us to discuss putative misuse of dextropropoxyphene. [source]

Tissue-engineered tear secretory system: Functional lacrimal gland acinar cells cultured on matrix protein-coated substrata

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH, Issue 1 2007
Shivaram Selvam
Abstract Dry eye is a general term that refers to a myriad of ophthalmic disorders resulting in the inadequate wetting of the corneal surface by the tear film. Dry eyes are typically treated by the application of artificial tears. However, patients with lacrimal insufficiencies such as Stevens-Johnson syndrome, chemical and thermal injuries, or ocular cicatricial pemphigoid have very limited options because of the short duration and action of lubricating agents. As a therapeutic strategy, we are working to develop a bioengineered tear secretory system for such patients. This article describes the growth and physiological properties of purified rabbit lacrimal gland acinar cells (pLGACs) on several matrix protein-coated polymers such as silicone, collagen I, copolymers of poly- D,L -lactide- co -glycolide (PLGA; 85:15 and 50:50), poly- L -lactic acid (PLLA), and Thermanox® plastic cell culture coverslips. Monolayers of acinar cells were established on all of the polymeric substrata. An assay of ,-hexosaminidase activity in the supernatant medium showed significant increases in protein secretion, following stimulation with 100 ,M carbachol on matrix protein-coated and uncoated polymers such as silicone, PLGA 85:15, and PLLA. Our study demonstrates that PLLA supported the morphological and physiological properties of purified rabbit lacrimal gland epithelial cells more successfully than the others. © 2006 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2007 [source]

Analysis of latent structures in linear models

JOURNAL OF CHEMOMETRICS, Issue 12 2003
Agnar Höskuldsson
Abstract In chemometrics the emphasis is on latent structure models. The latent structure is the part of the data that the modeling task is based upon. This paper addresses some fundamental issues that arise when latent structures are used. The paper consists of three parts. The first part is concerned with defining the latent structure of a linear model. Here the ,atomic' parts of the algorithms that generate the latent structure for linear models are analyzed. It is shown how the PLS algorithm fits within this way of presenting the numerical procedures. The second part concerns graphical illustrations, which are useful when studying latent structures. It is shown how loading weight vectors are generated and how they can be interpreted in analyzing the latent structure. It is shown how the covariance can be used to get useful a priori information on the modeling task. Some simple methods are presented for deciding whether a single or multiple latent structures should be used. The last part is about choosing the variables that should be used in the analysis. The traditional procedures for selecting variables to include in the model are presented and the insufficiencies of such approaches are demonstrated. A case study to illustrate the use of CovProc methods is presented. The CovProc methods are discussed and some of their advantages are presented. Copyright © 2004 John Wiley & Sons, Ltd. [source]

Defining a National Health Research and Practice Agenda for Older Adults with Intellectual Disabilities

JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES, Issue 1 2004
Philip W. Davidson
Abstract With the increasing number of adults with intellectual disabilities (ID) surviving into old age governments, provider agencies, and practitioners are recognizing the insufficiencies of available information related to the interaction of the aging process with lifelong disability, the incidence of disease and secondary conditions with advancing age, and the means to provide quality medical and health care. These insufficiencies were noted by a World Health Organization report that identified a need for more research on the health of older adults with IDs and reports from two meetings held by United States Public Health Service and the United States Surgeon General that examined health disparities among adults with ID. This paper reports the process and results of the Tampa Scientific Conference on Intellectual Disabilities, Aging, and Health, a meeting held in 2002 specifically to examine health issues germane to older adults with ID. The meeting produced a long-term research agenda for determining more effective physical and mental health outcomes for aging and older persons with ID and recommendations for aging-related medical and health surveillance practices that would improve the overall health status of adults with ID. [source]

Finite Element Modelling of Bioactive Contact in Bone-Implant Interface

PROCEEDINGS IN APPLIED MATHEMATICS & MECHANICS, Issue 1 2008
André Lutz
Finite element simulation for the prediction of bone remodelling caused by implants is a powerful method to improve or to rate implant designs even before they will be evaluated in clinical studies. But the bone,implant interaction is often modelled as ideal bonding in the interface. This approach is not suitable to describe the interrelation of both parts in a physiological manner. To correct these insufficiencies a 3D bioactive contact element has been developed. This contact element describes on the one hand the pure mechanical interaction and on the other hand the mechanical stimulated bone ingrowth in porous surfaces. The benefits of the use of the bioactive contact element regarding the standard method will be presented in this contribution. A comparison of both methods based on clinic results regarding a hip prosthesis with mixed surface textures will be shown. (© 2008 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim) [source]

Determinants of Placental Vascularity

AMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Issue 4 2004
Donald S. Torry
Problem:, Vascular growth during implantation and placentation is critical for successful gestation and it is thought that vascular insufficiencies during placentation contribute to a number of obstetrical complications. However, relatively little is known regarding the regulation of angiogenesis in the placenta. Method of study:, We review literature concerning the potential significance of inadequate placental vascularity as a contributor to the obstetrical complications of spontaneous abortion, fetal growth restriction and preeclampsia. Gene expression assays were used to compare fluctuations of placenta growth factor (PlGF) and PlGF receptor expression in normal and preeclamptic trophoblast in vitro. Results:, Studies have shown that common obstetrical complications manifest altered placental vascularity. Both intrinsic defects (gene knockouts) and extrinsic factors (O2 tension, cytokines, etc) may be responsible for the defects. Some of these factors have been shown to influence trophoblast vascular endothelial growth factor (VEGF)/PlGF expression suggesting this particular family of angiogenic proteins play an important role in placental angiogenesis. Conclusion:, Placental vascularization reflects a complex interaction of regulatory factors. Understanding the regulation of vascular growth in the placenta will provide much needed insight into placenta-related vascular insufficiencies. [source]

Assessing and Documenting General Competencies in Otolaryngology Resident Training Programs,

THE LARYNGOSCOPE, Issue 5 2006
Rick M. Roark PhD
Abstract Objectives: The objectives of this study were to: 1) implement web-based instruments for assessing and documenting the general competencies of otolaryngology resident education, as outlined by the Accreditation Council of Graduate Medical Education (ACGME); and 2) examine the benefit and validity of this online system for measuring educational outcomes and for identifying insufficiencies in the training program as they occur. Methods: We developed an online assessment system for a surgical postgraduate education program and examined its feasibility, usability, and validity. Evaluations of behaviors, skills, and attitudes of 26 residents were completed online by faculty, peers, and nonphysician professionals during a 3-year period. Analyses included calculation and evaluation of total average performance scores of each resident by different evaluators. Evaluations were also compared with American Board of Otolaryngology-administered in-service examination (ISE) scores for each resident. Convergent validity was examined statistically by comparing ratings among the different evaluator types. Results: Questionnaires and software were found to be simple to use and efficient in collecting essential information. From July 2002 to June 2005, 1,336 evaluation forms were available for analysis. The average score assigned by faculty was 4.31, significantly lower than that by nonphysician professionals (4.66) and residents evaluating peers (4.63) (P < .001), whereas scores were similar between nonphysician professionals and resident peers. Average scores between faculty and nonphysician groups showed correlation in constructs of communication and relationship with patients, but not in those of professionalism and documentation. Correlation was observed in respect for patients but not in medical knowledge between faculty and resident peer groups. Resident ISE scores improved in the third year of the study and demonstrated high correlation with faculty perceptions of medical knowledge (r = 0.65, P = .007). Conclusions: Compliance for completion of forms was 97%. The system facilitated the educational management of our training program along multiple dimensions. The small perceptual differences among a highly selected group of residents have made the unambiguous validation of the system challenging. The instruments and approach warrant further study. Improvements are likely best achieved in broad consultation among other otolaryngology programs. [source]

Impact of daily consumption of iron fortified ready-to-eat cereal and pumpkin seed kernels (Cucurbita pepo) on serum iron in adult women

BIOFACTORS, Issue 1 2007
Mohammad Reza Naghii
Abstract Iron deficiency, anemia, is the most prevalent nutritional problem in the world today. The objective of this study was to consider the effectiveness of consumption of iron fortified ready-to-eat cereal and pumpkin seed kernels as two sources of dietary iron on status of iron nutrition and response of hematological characteristics of women at reproductive ages. Eight healthy female, single or non pregnant subjects, aged 20,37 y consumed 30 g of iron fortified ready-to-eat cereal (providing 7.1 mg iron/day) plus 30 g of pumpkin seed kernels (providing 4.0 mg iron/day) for four weeks. Blood samples collected on the day 20 of menstrual cycles before and after consumption and indices of iron status such as reticulocyte count, hemoglobin (Hb), hematocrit (Ht), serum ferritin, iron, total iron-binding capacity (TIBC), transferrin and transferrin saturation percent were determined. Better response for iron status was observed after consumption period. The statistical analysis showed a significant difference between the pre and post consumption phase for higher serum iron (60 ± 22 vs. 85 ± 23 ug/dl), higher transferrin saturation percent (16.8 ± 8.0 vs. 25.6 ± 9.0%), and lower TIBC (367 ± 31 vs. 339 ± 31 ug/dl). All individuals had higher serum iron after consumption. A significant positive correlation (r = 0.981, p = 0.000) between the differences in serum iron levels and differences in transferrin saturation percentages and a significant negative correlation (r = ,0.916, p < 0.001) between the differences in serum iron levels and differences in TIBC was found, as well. Fortified foods contribute to maintaining optimal nutritional status and minimizing the likelihood of iron insufficiencies and use of fortified ready-to-eat cereals is a common strategy. The results showed that adding another food source of iron such as pumpkin seed kernels improves the iron status. Additional and longer studies using these two food products are recommended to further determine the effect of iron fortification on iron nutrition and status among the target population, and mainly in young children, adolescents, women of reproductive ages and pregnant women. [source]

REVIEW ARTICLE: Reducing fracture risk with calcium and vitamin D

CLINICAL ENDOCRINOLOGY, Issue 3 2010
Paul Lips
Summary Studies of vitamin D and calcium for fracture prevention have produced inconsistent results, as a result of different vitamin D status and calcium intake at baseline, different doses and poor to adequate compliance. This study tries to define the types of patients, both at risk of osteoporosis and with established disease, who may benefit from calcium and vitamin D supplementation. The importance of adequate compliance in these individuals is also discussed. Calcium and vitamin D therapy has been recommended for older persons, either frail and institutionalized or independent, with key risk factors including decreased bone mineral density (BMD), osteoporotic fractures, increased bone remodelling as a result of secondary hyperparathyroidism and increased propensity to falls. In addition, treatment of osteoporosis with a bisphosphonate was less effective in patients with vitamin D deficiency. Calcium and vitamin D supplementation is a key component of prevention and treatment of osteoporosis unless calcium intake and vitamin D status are optimal. For primary disease prevention, supplementation should be targeted to those with dietary insufficiencies. Several serum 25-hydroxyvitamin D (25(OH)D) cut-offs have been proposed to define vitamin D insufficiency (as opposed to adequate vitamin D status), ranging from 30 to 100 nmol/l. Based on the relationship between serum 25(OH)D, BMD, bone turnover, lower extremity function and falls, we suggest that 50 nmol/l is the appropriate serum 25(OH)D threshold to define vitamin D insufficiency. Supplementation should therefore generally aim to increase 25(OH)D levels within the 50,75 nmol/l range. This level can be achieved with a dose of 800 IU/day vitamin D, the dose that was used in succesfull fracture prevention studies to date; a randomized clinical trial assessing whether higher vitamin D doses achieve a greater reduction of fracture incidence would be of considerable interest. As calcium balance is not only affected by vitamin D status but also by calcium intake, recommendations for adequate calcium intake should also be met. The findings of community-based clinical trials with vitamin D and calcium supplementation in which compliance was moderate or less have often been negative, whereas studies in institutionalized patients in whom medication administration was supervised ensuring adequate compliance demonstrated significant benefits. [source]

Hypopituitarism is uncommon after aneurysmal subarachnoid haemorrhage

CLINICAL ENDOCRINOLOGY, Issue 1 2010
Marianne Klose
Summary Objective, Aneurysmal subarachnoid haemorrhage (SAH) has recently been reported as a common cause of chronic hypopituitarism, and introduction of routine neuroendocrine screening has been advocated. We aimed at estimating the risk of hypopituitarism after SAH using strict criteria including confirmatory testing in case of suggested insufficiency. Design, Cross-sectional evaluation with a nested prospective subgroup. Patients and measurements, Endocrine evaluation was performed at a median of 14 months (range 11,26) post-SAH in 62 patients with SAH and 30 healthy controls. Twenty-six patients were followed prospectively (median 7 days, and 12 months post-SAH). Endocrine evaluation included baseline evaluation, which was combined with an insulin tolerance test (ITT) or, if contraindicated, GHRH + arginine tests and a standard ACTH test at evaluation 1,2 years post-SAH. Pituitary insufficiencies were confirmed by re-evaluation. Results, Early post-SAH hormone alterations mimicking central hypogonadism were present in 58% of the patients and associated with a worse clinical state (P < 0·05). One to 2 years post-SAH, initial neuroendocrine evaluation identified seven patients (11%) with abnormal results; three had free T4 and TSH suggestive of central hypothyroidism, three men had testosterone below 10 nm, and one had an insufficient GH and cortisol response to the ITT. None of these abnormalities was confirmed upon confirmatory testing. Conclusion, In the largest reported cohort of patients with SAH to date, with early and late endocrine evaluation, none of the patients had chronic hypopituitarism. Based on these findings, the introduction of routine neuroendocrine screening is not justified, and the data suggest the importance of using strict diagnostic criteria in patients with a low pretest probability of hypopituitarism. [source]

Selective Application of the Pediatric Ross Procedure Minimizes Autograft Failure

CONGENITAL HEART DISEASE, Issue 6 2008
David L.S. Morales MD
ABSTRACT Objective., Pulmonary autograft aortic root replacement (Ross' operation) is now associated with low operative risk. Recent series suggest that patients with primary aortic insufficiency have diminished autograft durability and that patients with large discrepancies between pulmonary and aortic valve sizes have a low but consistent rate of mortality. Therefore, Ross' operation in these patients has been avoided when possible at Texas Children's Hospital. Our objective was to report outcomes of Ross' operation when selectively employed in pediatric patients with aortic valve disease. Methods., Between July 1996 and February 2006, 55 patients (mean age 6.8 ± 5.5 years) underwent Ross' procedure. Forty-seven patients (85%) had a primary diagnosis of aortic stenosis, three (5%) patients had congenital aortic insufficiency, and five (9%) patients had endocarditis. Forty-two (76%) patients had undergone prior aortic valve intervention (23 [55%] percutaneous balloon aortic valvotomies, 12 [29%] surgical aortic valvotomies, 12 [29%] aortic valve replacements, 2 [5%] aortic valve repairs). Fourteen (25%) patients had ,2 prior aortic valve interventions. Thirty-two patients (58%) had bicuspid aortic valves. Follow-up was 100% at a mean of 3 ± 2.5 years. Results., Hospital and 5-year survival were 100% and 98%, respectively. Morbidity included one reoperation (2%) for bleeding. Median length of hospital stay was 6 days (3 days,3 months). Six (11%) patients needed a right ventricular to pulmonary artery conduit exchange at a median time of 2.3 years. Freedom from moderate or severe neoaortic insufficiency at 6 years is 97%. Autograft reoperation rate secondary to aortic insufficiency or root dilation was 0%. Conclusions., By selectively employing Ross' procedure, outcomes of the Ross procedure in the pediatric population are associated with minimal autograft failure and mortality at mid-term follow-up. [source]

The chemotaxis defect of Shwachman-Diamond Syndrome leukocytes

CYTOSKELETON, Issue 3 2004
Vesna Stepanovic
Abstract Shwachman-Diamond Syndrome (SDS) is a rare autosomal recessive, multisystem disorder presenting in childhood with intermittent neutropenia and pancreatic insufficiency. It is characterized by recurrent infections independent of neutropenia, suggesting a functional neutrophil defect. While mutations at a single gene locus (SBDS) appear to be responsible for SDS in a majority of patients, the function of that gene and a specific defect in SDS neutrophil behavior have not been elucidated. Therefore, employing 2D and 3D computer-assisted motion analysis systems, we have analyzed the basic motile behavior and chemotactic responsiveness of individual polymorphonuclear leukocytes (PMNs) of 14 clinically diagnosed SDS patients. It is demonstrated that the basic motile behavior of SDS PMNs is normal in the absence of chemoattractant, that SDS PMNs respond normally to increasing and decreasing temporal gradients of the chemoattractant fMLP, and that SDS PMNs exhibit a normal chemokinetic response to a spatial gradient of fMLP. fMLP receptors were also distributed uniformly through the plasma membrane of SDS PMNs as in control PMNs. SDS PMNs, however, were incapable of orienting in and chemotaxing up a spatial gradient of fMLP. This unique defect in orientation was manifested by the PMNs of every SDS patient tested. The PMNs of an SDS patient who had received an allogenic hematopoietic stem cell transplant, as well as PMNs from a cystic fibrosis patient, oriented normally. These results suggest that the defect in SDS PMNs is in a specific pathway emanating from the fMLP receptor that is involved exclusively in regulating orientation in response to a spatial gradient of fMLP. This pathway must function in parallel with additional pathways, intact in SDS patients, that emanate from the fMLP receptor and regulate responses to temporal rather than spatial changes in receptor occupancy. Cell Motil. Cytoskeleton 57:158,174, 2004. © 2004 Wiley-Liss, Inc. [source]

Immediate Pathologic Effects on the Vein Wall of Foam Sclerotherapy

DERMATOLOGIC SURGERY, Issue 10 2007
CAMILLO ORSINI MD
BACKGROUND During the past 10 years, sclerotherapy has radically changed, the foam sclerotherapy method being better than that of liquid sclerotherapy. OBJECTIVES We have analyzed the immediate pathologic effects on the saphenous vein wall in vivo after sclerotherapy with sodium tetradecyl sulfate (STD) foam. METHODS A group of six patients affected by chronic venous insufficiency, operated on by stripping of the saphenous vein, underwent an intraoperative procedure of sclerotherapy to an isolated but not yet removed tract of saphenous vein with 3% STD foam. RESULTS The pathologic damage of the foam was extremely rapid with complete damage of the endothelium within the first 2 minutes. In the successive 15 and 30 minutes there was edema of the intimal with its progressive separation from the tunica media and the initial formation and adhesion of the thrombus to the tunica media. CONCLUSIONS In this in vivo report we analyze the capacity of 3% STD foam sclerotherapy to damage the saphenous vein wall. The damage is extremely fast and shows the detachment of the intimal and the development of the microthrombus. [source]