Complete resolution of chylopericardium after chemotherapy for chronic lymphocytic leukemia.

Nontraumatic chylous pleural effusions (chylothorax) and pericardial effusions (chylopericardium) are rare. They can, however, accompany intrathoracic malignancies and, most commonly, lymphomas. An association of chronic lymphocytic leukemia (cll) with chylopericardium has rarely been reported. A 68-year-old woman with cll, previously treated with single-agent fludarabine in the community, developed pleuritic chest pain and a new pericardial effusion. Computed tomography (ct) imaging of her chest revealed a large pericardial effusion with progressive lymphadenopathy. Pericardiocentesis identified a chylous effusion, and complete evacuation was achieved by catheter drainage. The cll was not treated. An asymptomatic pericardial effusion subsequently recurred. Pericardiocentesis was not repeated. Lymph node biopsy and flow cytometry revealed no evidence of large-cell lymphoma transformation. The patient was treated with 6 cycles of chlorambucil and obinutuzumab. Imaging of her chest by ct between cycles 2 and 3 revealed a marked resolution of the intrathoracic lymphadenopathy, with complete disappearance of the pericardial effusion. Repeat imaging at 5 months and again at 3 years after completion of chemotherapy demonstrated no recurrence of either the lymphadenopathy or the pericardial effusion. The mechanism of production and the treatment of chylous effusions are poorly defined. In this case, resolution of the pericardial effusion with effective chemotherapy is postulated to have alleviated obstruction of anterograde lymphatic flow facilitating drainage into the systemic venous system and allowing for spontaneous complete resolution of the pericardial effusion without surgical intervention.

ABCA1 and amphipathic apolipoproteins form high-affinity molecular complexes required for cholesterol efflux.

Apolipoproteins, such as apolipoprotein A-I (apoA-I), can stimulate cholesterol efflux from cells expressing the ATP binding cassette transporter A1 (ABCA1). The nature of the molecular interaction between these cholesterol acceptors and ABCA1 is controversial, and models suggesting a direct protein-protein interaction or indirect association have been proposed. To explore this issue, we performed competition binding and chemical cross-linking assays using six amphipathic plasma proteins and an 18 amino acid amphipathic helical peptide. All seven proteins stimulated lipid efflux and inhibited the cross-linking of apoA-I to ABCA1. Cross-linking of apoA-I to ABCA1 was saturable and occurred at high affinity (Kd of 7.0 +/- 1.9 nM), as was cross-linking of apoA-II. After binding to ABCA1, apoA-I rapidly dissociated (half-life of 25 min) from the complex and was released back into the medium. A mutant form of ABCA1 (W590S) that avidly binds apoA-I but fails to promote cholesterol efflux released apoA-I with similar kinetics but without transfer of cholesterol to apoA-I. Thus, a high-affinity, saturable, protein-protein interaction occurs between ABCA1 and all of its amphipathic protein ligands. Dissociation of the complex leads to the cellular release of cholesterol and the apolipoprotein. However, dissociation is not dependent on cholesterol transfer, which is a clearly separable event, distinguishable by ABCA1 mutants.

Identity and similarity in repetition blindness: no cross-over interaction.

The difficulty in reporting both occurrences of a repeated item is a phenomenon referred to as repetition blindness (RB). RB has been proposed to result from temporal limitations in creating separate episodic tokens for a twice-activated type. Recently, Chialant and Caramazza (Cognition 63 (1997) 79-119) disputed the conventional view that RB for non-identical words (orthographic RB, as in lice and lick) results from the same mechanism as identity RB, and proposed that orthographic RB arises from competition for lexical selection. Supporting evidence was that identical and merely similar words showed different amounts of RB as a function of stimulus onset asynchrony (lag). Four experiments failed to replicate Chialant and Caramazza's finding that identity RB decreases, but orthographic RB increases, as a function of lag. Instead, RB for all stimuli, including homonym pairs, declined monotonically with lag. These results are consistent with a common mechanism underlying RB for identical and orthographically similar words and with prior research suggesting that RB in similar words occurs at a sublexical level.

Illusory words created by repetition blindness: a technique for probing sublexical representations.

When two orthographically similar words are displayed using rapid serial visual presentation (RSVP), the repeated letters in the second critical word (W2) are not detected, leading to a deficit in reporting this word, a phenomenon known as repetition blindness (RB). The unrepeated letters in W2 do appear to be detected and available to feed activation to words compatible with them (Morris & Harris, 1999). When a fragment was strategically placed in the RSVP stream, as in GROW throw ank, observers reported seeing thank more often than in the control condition BEAT throw ank. Illusory words were facilitated by repetition blindness only when the recombining letters maintained their position in the words. Illusory word report was insensitive to the phonological similarity of the recombining letters; equal quantities of illusory words were created by sequences like china CHEAT THR (-->threat) and swung SWEAT THR (-->threat). In addition to being an interesting phenomenon in its own right, the illusory words paradigm may have considerable use as a tool for probing the perceptual units underlying visual word recognition.

Increased prevalence of gastroesophageal reflux symptoms in patients with COPD.

STUDY OBJECTIVES: To determine the prevalence of gastroesophageal reflux (GER) symptoms in patients with COPD and the association of GER symptoms with the severity of airways obstruction as assessed by pulmonary function tests (PFTs). DESIGN: Prospective questionnaire-based, cross-sectional analytic survey. SETTING: Outpatient pulmonary and general medicine clinics at a Veterans Administration hospital. PATIENTS: Patients with mild-to-severe COPD (n = 100) were defined based on American Thoracic Society criteria. The control group (n = 51) consisted of patients in the general medicine clinic without respiratory complaints or prior diagnosis of asthma or COPD. INTERVENTION: Both groups completed a modified version of the Mayo Clinic GER questionnaire. RESULTS: Compared to control subjects, a greater proportion of COPD patients had significant GER symptoms defined as heartburn and/or regurgitation once or more per week (19% vs 0%, respectively; p < 0.001), chronic cough (32% vs 16%; p = 0.03), and dysphagia (17% vs 4%; p = 0.02). Among patients with COPD and significant GER symptoms, 26% reported respiratory symptoms associated with reflux events, whereas control subjects denied an association. Significant GER symptoms were more prevalent in COPD patients with FEV(1) < or %, as compared with patients with FEV(1) > 50% of predicted (23% vs 9%, respectively; p = 0.08). In contrast, PFT results were similar among COPD patients with and without GER symptoms. An increased number of patients with COPD utilized antireflux medications, compared to control subjects (50% vs 27%, respectively; p = 0.008). CONCLUSIONS: The questionnaire demonstrated a higher prevalence of weekly GER symptoms in patients with COPD, as compared to control subjects. There was a trend toward higher prevalence of GER symptoms in patients with severe COPD; however, this difference did not reach statistical significance. We speculate that although GER may not worsen pulmonary function, greater expiratory airflow limitation may worsen GER symptoms in patients with COPD.

Orthographic repetition blindness.

Repetition blindness (RB) is the failure to report the second occurrence of a repeated word, when words are sequentially and briefly displayed (Kanwisher, 1987). RB is also observed for non-identical words, such as home, dome. Explanations for non-identity RB assume that similarity at the level of the whole word causes the second word to be suppressed ("similarity inhibition"). Three experiments demonstrate that RB is robust for diverse types of orthographic relatedness, including critical words that share only their first initial letter, their last two letters, first three letters, middle three letters, beginning and final letters, three alternating letters, and three non-aligned letters (as in chance hand). The theoretical construct of similarity inhibition may be able to account for these data, although one mechanism previously proposed in the literature, neighbourhood inhibition, is probably not a useful way to explain the data on RB for words sharing only one or two letters. We introduce an alternative explanation for orthographic RB: Only the repeated letters are suppressed, and amount of RB depends on how easily the perceiver can reconstruct the target word from the non-suppressed letters.

Reactivation of coagulation after stopping infusions of recombinant hirudin and unfractionated heparin in unstable angina and myocardial infarction without ST elevation: results of a randomized trial. OASIS Pilot Study Investigators. Organization to Assess Strategies for Ischemic++ Syndromes.

AIMS: To compare effects of heparin and hirudin on biochemical markers of coagulation. METHODS AND RESULTS: Patients (n=395) with unstable angina or myocardial infarction without ST elevation were randomized to a 72-h infusion of one of three regimens: unfractionated heparin (bolus of 5000 IU followed by an infusion of 1200 IU. h(-1)), low-dose hirudin (HBW 023; 0.2 mg. kg(-1)bolus followed by 0.10 mg. kg(-1). h(-1)) or medium-dose hirudin (0.4 mg. kg(-1)bolus followed by 0.15 mg. kg(-1). h(-1)). Infusions were adjusted to maintain an activated partial thromboplastin time of between 60-100 s. Activated partial thromboplastin time, prothrombin fragment 1.2 (F1.2), thrombin antithrombin III complex and D-dimer were measured before, during and after the infusion. Median activated partial thromboplastin time was similar in the two groups early on, but was significantly lower in the heparin group than in the combined hirudin group 48 h after starting the infusion (53 s and 75 s, respectively;P<0.001), and 6 h after stopping (31 s and 46 s, respectively;P<0.001). Median F1.2 levels were not significantly different between the groups during the infusion. Median thrombin antithrombin III levels in the heparin and hirudin groups were 2.8 microg. l(-1)and 2.3 microg. l(-1), respectively, at 6 h (P<0.001), and 3.0 microg. l(-1)and 2.3 microg. l(-1), respectively, at 48 h (P<0.001). Median D-dimer levels were 320 ng. ml(-1)and 260 ng. ml(-1)48 h after starting the infusion in the heparin and hirudin groups, respectively (P<0.001), and 415 ng. ml(-1)and 280 ng. ml(-1), respectively (P<0.001) 6 h after stopping. D-dimer levels were significantly elevated above baseline values in both groups 24-48 h after stopping the infusions. CONCLUSIONS: The greater reduction of thrombin antithrombin III and D-dimer during the hirudin infusion supports the hypothesis that hirudin is a more potent antithrombin agent than heparin. Increased D-dimer levels after stopping heparin or hirudin suggest that there is an ongoing pro-coagulant state. These results point to the greater efficacy of hirudin in preventing early clinical events (death, myocardial infarction and refractory ischaemia) compared with heparin that have been observed in large randomized trials. Persistent activation of coagulation afterstopping infusions in our study suggests that a longer course of antithrombotic treatment may be needed to pacify the thrombus.

A sublexical locus for repetition blindness: evidence from illusory words.

Six experiments used an illusory words paradigm to demonstrate that repetition blindness (RB) in orthographically similar words affects only the words' shared letters. Rapid serial visual presentation streams of words and word fragments allowed the unique letters of the 2nd critical word to combine with a subsequent fragment to create a word, as in rock shock ell. The illusory word shell was reported 2-3 times as frequently in RB conditions as in control conditions. Further experiments ruled out letter migration, contour summation, and differences in processing load as explanations for the results. These findings are inconsistent with current proposals that orthographic RB represents similarity inhibition or lexical competition or that it reflects problems with word-level token individuation.

Technology to help family carers: innovative U.S. dissemination strategies.

Life could be easier, safer, and more independent for millions of older Americans if their homes were better suited to their changing needs. The most common less felt by those growing older can be compensated for to some degree through the use of technology products and or home modification. Most older adults noting difficulty in routine activities attribute the cause to physical change within their own body. The older adult or carer rarely considers the fact that the home itself or the tools chosen for activity performance may be exaggerating an individual's changing abilities. Implementation of the programs described in this paper increase community education potential. Consumers, carers, and service providers can better recognize the utility of technology as a strategy for more successful aging.

Coronary angiography and bypass surgery in Manitoba and the United States: a first comparison.

OBJECTIVE: To compare the appropriateness of use of coronary angiography (CA) and bypass surgery (CABS) in the early 1980s in one Canadian hospital and several American hospitals using explicit case-based criteria. Procedure rates were much lower in Canada during this period. SUBJECTS: Canadian subjects, 502 Manitoba residents undergoing CA at one hospital in 1981-82 were tracked forward to determine whether and when they underwent CABS. CA comparisons were made with 351 Canadian patients aged 55 years or older; 1677 American CA patients aged 65 years or older and were drawn in 1981 from three hospitals. Two hundred and forty-five patients undergoing CABS within 12 months of CA made up the Canadian sample. American CABS patients were sampled from three hospitals during 1979-82. Manitoba patients assigned to medical treatment after CA were also appraised. METHODS: Criteria were derived by an American panel of clinicians following a Delphi process; indications were rated appropriate, equivocal and inappropriate. A trained abstractor reviewed charts and assigned ratings. Results of exercise electrocardiograms were not available in the Manitoba data set, hence sensitivity analyses were performed to determine how differing proportions of positive exercise electrocardiograms might affect the Manitoba results. RESULTS: Even assuming only 50% of treadmill tests were positive in the Manitoba sample, the proportion of inappropriate CA was lower in Manitoba than for the American hospitals: 9% versus 15 to 18%. For CABS, only one of the three comparison American hospitals approached the Manitoba hospital level of appropriateness. CONCLUSIONS: In the early 1980s, there was more appropriate use of CA and CABS in a Manitoba hospital compared with several American hospitals. Many Canadian patients undergoing CA and treated medically met American indications for appropriate use of CABS. Whether this represents underprovision of necessary care remains uncertain.

Case report. Pediatric carpal fracture dislocation.

Transcarpal fractures in children are rare in the orthopaedic literature. This is a case report of a 10-year-old boy who sustained fractures across the distal radius, scaphoid, lunate, and triquetrum with gross displacement. Treatment consisted of open reduction with internal fixation of the fractures and ligamentous repair through a combined dorsal and palmar approach. The injury healed with good wrist function but abnormal carpal development. This unusual pattern of injury is described so that it may be more readily appreciated in the future.

Stereochemical quality of protein structure coordinates.

Methods have been developed to assess the stereochemical quality of any protein structure both globally and locally using various criteria. Several parameters can be derived from the coordinates of a given structure. Global parameters include the distribution of phi, psi and chi 1 torsion angles, and hydrogen bond energies. There are clear correlations between these parameters and resolution; as the resolution improves, the distribution of the parameters becomes more clustered. These features show a broad distribution about ideal values derived from high-resolution structures. Some structures have tightly clustered distributions even at relatively low resolutions, while others show abnormal scatter though the data go to high resolution. Additional indicators of local irregularity include proline phi angles, peptide bond planarities, disulfide bond lengths, and their chi 3 torsion angles. These stereochemical parameters have been used to generate measures of stereochemical quality which provide a simple guide as to the reliability of a structure, in addition to the most important measures, resolution and R-factor. The parameters used in this evaluation are not novel, and are easily calculated from structure coordinates. A program suite is currently being developed which will quickly check a given structure, highlighting unusual stereochemistry and possible errors.

Assessing dental practice quality by evaluating radiology items.

The DEMCAD dental office assessment instrument was developed to evaluate practice quality using Donebedian's quality assessment model of structure, process, and outcome. This previously validated instrument takes about six hours to complete. Subsequent analysis was undertaken to determine whether an abbreviated office assessment based on the evaluation of radiology items was sufficiently sensitive, specific, and practical to be used as a screening instrument for identifying dental offices with very low evaluation scores. Data for this analysis were obtained from 300 volunteer general dental practices evaluated in the field testing of the DEMCAD instrument. The nine radiology structure items predicted very poorly the overall structure scores. However, 13 radiology process items predicted overall process scores quite accurately. Four of the 13 radiology process items (periodontal diagnoses recorded, interdental bone shown on x-rays, caries diagnoses recorded, and current x-rays mounted) produced a combined R2 of .58. These four radiology variables predicted the 10 percent of the dental practices with the lowest overall process score with 87 percent sensitivity and 93 percent specificity. This analysis showed that an abbreviated dental practice process quality assessment using oral radiology items in an audit of patients' records may be feasible as a screening test for dental office assessment.

Managing scarce services. A waiting list approach to cardiac catheterization.

Relatively little attention has been directed to the provision of health care services when demand exceeds availability. Since "waiting lists" are characteristic of the delivery of cardiovascular services in Manitoba, we hypothesized that the highest priority would be given to cases with the greatest urgency. This study examined the waiting lists for cardiac catheterization in one of two tertiary health care facilities offering comprehensive cardiovascular care to a population of slightly more than one million persons. Hospital records of all patients undergoing cardiac catheterization from May 1981 through December 1982 were abstracted retrospectively. For 871 patients entering a catheterization laboratory by two different routes (Elective Care, N = 557; Immediate Care, N = 314), patient need for immediate catheterization was assessed. Clinical differences between patients in the two groups were striking. Immediate Care patients more frequently had acute congestive heart failure, prior aortic valve surgery, and chronic obstructive pulmonary disease. Immediate Care patients were most frequently in Class 4 of the NYHA functional classification and were more often treated with triple medical therapy. These clinically ill individuals were more likely to enter the hospital via the Emergency Room; they were more likely to have long hospital stays and to die in hospital. As implemented in one Manitoba hospital, the waiting list process appears to have worked fairly well; cardiac arrest, acute myocardial infarction, and death among patients waiting for catheterization were all rare events. Both those patients needing immediate care and those who could wait with a low probability of a poor outcome were successfully identified.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of radiographic equipment and procedures in 300 dental offices in the United States.

As part of the development and testing of a dental practice quality assessment instrument, data were gathered regarding the radiological practices of a nationwide sample of 300 general dentistry offices. The distribution of assessment scores was compared for practice size (solo versus nonsolo) and practice age (1-19 years versus 20 or more years). Practice habits varied widely, from a high of 99% of the offices using a leaded apron to a low of 23% of the offices having a written policy regarding the use of ionizing radiation. Most offices successfully managed administrative items such as mounting and dating radiographs. However, for items such as radiographic exposure, tissue coverage, and radiographic interpretation, general performance was fair.

Relationships among structure, process, and outcome scores derived from evaluations of 300 general dental practices.

Analyses were undertaken to examine relationships among measures of structure, process, and outcome using data obtained during field testing of the Development of Evaluation Methods and Computer Applications in Dentistry (DEMCAD) office assessment instrument in 300 general dental practices. Correlation coefficients between scores for the structure dimension and scores for the process/outcome dimensions were 0.50 and 0.40, respectively, while process and outcome dimension scores were correlated at an even higher level (r = 0.79). Thus the DEMCAD instrument demonstrated a relatively high degree of interrelationship among these three major dimensions compared to other reports in the health care evaluation literature. Additional analyses were conducted to compare relationships between structure and process measures and various components of outcome, and to compare results across different types of practices (urban group, rural and urban nongroup). Correlations between the patient satisfaction component of outcome and scores for the structure/process dimensions were considerably lower than the corresponding correlations involving outcome components other than patient satisfaction. Ordinary least squares regression models demonstrated that structure scores were not significantly related to outcomes when controlling for process and that relationships were quite consistent across practice types.

Prophylaxis of post-myocardial infarction dysrhythmias by long-term timolol therapy.

The antiarrhythmic efficacy of timolol maleate was assessed in 94 patients with acute myocardial infarction. No significant differences were noted between early treatment with timolol and placebo in the mean and peak hourly ventricular premature complex rates, ventricular premature complex couplets, or runs. However, compared to the placebo treatment, there was a significant (p less than 0.001) 66% reduction in the relative fraction of early-cycle ventricular premature complexes 7 to 9 days after initiation of timolol therapy and a more prolonged significant (p less than 0.001) 73% reduction in the fraction of early-cycle supraventricular complexes throughout the 28-day timolol and placebo comparison period. The frequency distribution of QRS duration was significantly different between the placebo- and timolol-treated patients, with the mean duration 8 msec longer in the placebo-treated patients (p = 0.008). Adverse effects from early administration of timolol did not differ from those in the placebo-treated patients.

Assessment of private dental practice: implications for dental education.

The development and testing methods for assessing the quality of private general dental practice are described. The assessment instrument, evolved through the contributions of a panel of private practitioners, provides for the evaluation of the structure, process, and outcome of practice. General practitioners, trained as evaluators, tested the instrument in 300 urban group, urban nongroup, and rural practices in 14 states. The distribution of assessment scores for the entire project sample is compared with those of the sample dentists who graduated before and after 1974. The implications of the project and its results to dental education are discussed.