[So-called spontaneous intramural dissection of the esophagus]. / Dissection intramurale dite "spontanée" de l'oesophage.

We report two cases of spontaneous esophageal intramural dissection in two women aged 65 and 79 years. Initial symptoms were a constrictive retrosternal thoracic pain during a meal. Minor hematemesis accompanied by dysphagia or odynophagia appeared during the following hours. After excluding a cardiovascular emergency, diagnosis was confirmed by upper GI endoscopy that found a large mucosal longitudinal dissection; the lesion extended from mid-esophagus until short above the gastro-esophageal junction. Intramural parietal dissection characteristically appeared on barium swallow as a "double-barrelled" esophagus related to a thin radiolucent mucosal membrane separating the false and true lumens. Medical treatment with total parenteral nutrition, intravenous gastric antisecretory drugs, antibiotics in 1 patient was continued until symptoms disappeared; oral feeding was then started without incident. Follow-up endoscopic examinations confirmed complete healing. Regardless of etiology which remains speculative, spontaneous intramural dissection of the esophagus probably results from an intramural hematoma in most cases.

Effectiveness of the Quick Medical Reference as a diagnostic tool.

A number of computer-based systems with diagnostic capabilities have been developed for internal medicine. Quick Medical Reference (QMR) is one such program. The authors describe key features of QMR and report on their study of its effectiveness as a diagnostic tool. They investigated how frequently the correct diagnosis would appear among the 5 highest ranked diagnoses generated by QMR. The charts of 1144 consecutive patients admitted to a teaching unit were retrospectively screened. Eligible cases included those referred for investigation of an undiagnosed illness with an objectively proven final diagnosis (n = 154). Two physicians familiar with, but not experts in, the use of QMR entered clinical information abstracted from the patients' charts into the program. Physician A obtained the correct diagnosis in 62 (40%) of the 154 cases, and physician B was successful in 56 (36%) of the cases. The authors use study cases to illustrate QMR's strengths and weaknesses.

Hyperhomocyst(e)inemia and the prevalence of atherosclerotic vascular disease in patients with end-stage renal disease.

Hyperhomocyst(e)inemia is now recognized as an independent risk factor for atherosclerotic cardiovascular disease in patients with normal renal function. Hyperhomocyst(e)inemia is common in patients with chronic renal failure. This study is designed to look for an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients with end-stage renal disease (ESRD). Two hundred eighteen patients undergoing hemodialysis were enrolled onto the study and had predialysis bloodwork performed for total homocyst(e)ine, red blood cell folate, and vitamin B(12) levels. A history of clinically significant atherosclerotic vascular disease (ischemic heart disease, cerebrovascular disease, or peripheral vascular disease) was elicited by patient questionnaire and verified by careful inpatient and outpatient chart review. Atherosclerotic vascular disease was present in 45.9% of patients. Mean homocyst(e)ine concentration was 26.7 micromol/L (95% confidence interval [CI], 25.0 to 28.4) overall. Mean homocyst(e)ine concentration was 28.6 micromol/L (95% CI, 25.6 to 31.7) and 25.0 micromol/L (95% CI, 23.2 to 26.8) in patients with and without atherosclerotic disease, respectively (P = 0.036). The adjusted odds ratio for atherosclerotic disease was 2.12 (95% CI, 1.03 to 4.39) for those subjects with a homocyst(e)ine level in the highest quartile compared with the lowest 3 quartiles. In the 126 men, the adjusted odds ratio for atherosclerotic disease was 3.4 (95% CI, 1. 24 to 9.42) for those with homocyst(e)ine levels in the highest quartile compared with the lowest 3 quartiles. No association was found between homocyst(e)ine level and atherosclerotic disease in women. In conclusion, there is an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients undergoing dialysis. Prospective studies need to further examine the relationship between homocyst(e)ine level and atherosclerosis in women with ESRD.

Hyperhomocysteinemia, anticardiolipin antibody status, and risk for vascular access thrombosis in hemodialysis patients.

BACKGROUND: Vascular access failure is an important cause of morbidity in end-stage renal failure patients on hemodialysis. Currently, little is known about risk factors that predispose certain hemodialysis patients to recurrent access thrombosis. Hyperhomocysteinemia (common in patients with renal failure) predisposes people with normal renal function to recurrent and early-onset venous thrombosis, although the effect on vascular access thrombosis is currently unknown. Previous studies have suggested that high titers of IgG anticardiolipin antibody (IgG-ACA) predispose hemodialysis patients to access thrombosis. This cross sectional study was designed to assess for an association between two predictive variables, hyperhomocysteinemia and elevated titers of IgG-ACA, and vascular access thrombosis in patients undergoing chronic hemodialysis. METHODS: Risk factors for vascular access thrombosis were documented, and the number of episodes of access thrombosis was recorded for the previous three years in patients undergoing hemodialysis. Midweek predialysis total homocysteine and IgG-ACA levels were measured in all subjects. RESULTS: Of the 118 patients who were enrolled, 75.4% had a native arteriovenous fistula. Episodes of vascular access thrombosis were recorded for the previous three years; 34 (28.8%, 95% CI 20.9 to 37.9%) patients had 72 episodes of access thrombosis over the period of risk. Mean homocysteine levels were not significantly different between these 34 patients (28.6 micromol/liter, 95% CI 24.5 to 32.7) and the patients who had no episodes of graft thrombosis (29.8 micromol/liter, 95% CI 26.7 to 32.9). Sixty-seven unselected patients had IgG-ACA levels drawn for analysis, and all assays were negative. The only variable that was associated with a higher risk for graft thrombosis was the type of vascular access placed (odds ratio 4.0, 95% CI 1.6 to 9.6 for patients with a synthetic graft compared with those with an arteriovenous fistula). CONCLUSIONS: No association was found between homocysteine levels or anticardiolipin antibody and vascular access thrombosis in our patient population.

Ferrous sulphate interacts with captopril.

AIMS: To determine if iron binds strongly to captopril and reduces captopril absorption. METHODS: A variety of in vitro experiments was conducted to examine iron binding to captopril and a randomized, double-blind, placebo controlled, cross-over study design was used to assess the in vivo interaction. Captopril (25 mg) was coingested with either ferrous sulphate (300 mg) or placebo by seven healthy adult volunteers. Subjects were phlebotomized and had blood pressure measured at 0, 0.25, 0.5, 1, 2, 4, 6, 8, and 12 h post ingestion. A 1 week washout period was used. RESULTS: The coingestion of ferrous sulphate and captopril was associated with a 37% (134 ng ml(-1) h, 95% CI 41-228 ng ml(-1) h, P = 0.03) decrease in area under the curve (AUC) for unconjugated plasma captopril. There were no substantial changes in Cmax (mean difference; -32; 95% CI -124-62 ng ml(-1) (P = 0.57)) or in tmax (mean difference; 0; 95% CI -18-18 min (P = 0.65)) for unconjugated captopril when captopril was ingested with iron. There was a statistically insignificant increase in AUC for total plasma captopril of 43% (1312 ng ml(-1) h, 95% CI -827-3451 ng ml(-1) h P = 0.27) when captopril was ingested with iron. The addition of ferric chloride to captopril resulted in the initial rapid formation of a soluble blue complex which rapidly disappeared to be replaced by a white precipitant. The white precipitate was identified as captopril disulphide dimer. There were no significant differences in systolic and diastolic blood pressures between the treatment and placebo groups. CONCLUSIONS: Co-administration of ferrous sulphate and iron results in decreased unconjugated captopril levels likely due to a chemical interaction between ferric ion and captopril in the gastrointestinal tract. Care is required when coprescribing captopril and iron salts.

Folate status, vascular disease and cognition in elderly Canadians.

OBJECTIVE: To report on the relationship between serum folate levels and the prevalence of stroke, peripheral vascular disease, cognitive problems and short-term mortality in elderly people. SETTING AND PARTICIPANTS: 1171 subjects whose serum folate was determined as part of their clinical examination in the Canadian Study of Health and Aging, a population study of individuals 65 years and older. METHODS: Cross-sectional analysis compared relationships between serum folate levels and clinical features; longitudinal analysis examined mortality at follow-up by folate status at the time of the clinical examination. RESULTS: Membership in the lowest quartile for serum folate was associated with an increased likelihood of stroke. Those with low folate levels were more likely to be demented, institutionalized and depressed. In the cognitively impaired but not demented group, those with low folate levels scored lower on the Modified Mini Mental State and had more short-term memory problems. CONCLUSIONS: Low folate level was a significant explanatory variable for stroke. Low folate levels were common in all types of dementia and were associated with a history of weight loss, lower body mass index and lower serum albumin concentrations. This may reflect the reduced ability of cognitively impaired individuals to eat adequately.

The role of saliva in aggregation and adherence of Pseudomonas aeruginosa in patients with cystic fibrosis.

The aggregation and adherence activity of P. aeruginosa, mediated by whole saliva from cystic fibrosis (CF) patients and non-CF subjects, was investigated. CF saliva-mediated aggregation of P. aeruginosa was stronger than the activity of non-CF saliva. Likewise, P. aeruginosa adherence to buccal epithelial cells (BEC) of CF patients was stronger than to BEC of non-CF subjects. Adherence of non-mucoid P. aeruginosa to BEC of CF patients was increased by saliva, whereas the mucoid variant was not. CF patients colonized with P. aeruginosa showed higher adherence of the non-mucoid variant than non-colonized CF patients. CF patients with high saliva-mediated adherence of non-mucoid P. aeruginosa also had high salivary aggregation activity. Increased CF saliva-mediated aggregation activity may be linked to the increased non-mucoid P. aeruginosa adherence to BEC of CF patients.

[Mature lumbar multi-tissue dysembryoma of the spinal cord with sacral spina bifida occulta]. / Dysembryome pluritissulaire mature médullaire lombaire avec spina bifida occulta sacré.

The authors report the case of a 28-year-old woman who presented with L5 bilateral sciatica associated with perineal sensory disorders. During surgery, a mature pluritissular dysembryoma originating in a tethered spinal cord was discovered at the level of the L2-L3 intervertebral space. Following removal of the lesion, all symptoms disappeared. Mature pluritissular dysembryomas of the spinal cord result from the inclusion of neuroectodermal and mesodermal tissue which has not followed normal evolutive embryonic organization.

Group modification of affective verbalizations: reinforcement and therapist style effects.

Used an operant group paradigm to investigate the effects of reinforcement in combination with differing therapist styles upon affective verbalizations. Therapists' usage of direct questioning to elicit Ss' affective verbalizations proved quantitatively superior (in number of reinforceable responses) to either a no therapist or role modelling therapist condition (N = 72). There was evidence, however, that Ss in reinforced role modelling conditions were significantly better than direct elicitation Ss in predicting other group members' self-descriptions and in the degree to which Ss felt accurately perceived by others, while the reverse was true for non-reinforced Ss.