Are IVC filters required in combat support hospitals?

BACKGROUND: Haemorrhagic shock from traumatic injuries is now often treated using a damage control resuscitation strategy that transfuses packed red blood cells, plasma and platelets in a 1:1:1 ratio, early use of activated recombinant factor VII and transfusion of fresh whole blood. These therapies are aimed at promoting thrombosis in injured vessels. Such patients are at high risk for thrombotic complications and thromboprophylaxis is necessary, but frequently impossible to use in the early phase of care. CASE PRESENTATION: We describe the case of an Afghan civilian worker who suffered a vertical shear pelvic fracture with massive bleeding in a pedestrian/truck collision that was treated with a damage control resuscitation strategy, and who later suffered a severe pulmonary embolus. The potential use of a temporary inferior vena cava [IVC] filters is discussed. RECOMMENDATIONS: Care providers and policy makers must recognize that the increased use of prothrombotic strategies of resuscitation will likely increase the incidence of thrombotic complications in the high risk population of severely injured patients in combat support hospitals. Monitoring the incidence of these complications and development of strategies for prevention and treatment are required to avoid undermining the positive outcomes of damage control resuscitation. These strategies could include supplying combat support hospitals with the equipment and training necessary for placement of temporary IVC filters under fluoroscopic guidance.

Zinc toxicity following massive coin ingestion.

This is the first reported case of human fatality associated with zinc intoxication following a massive ingestion of coins. Four hundred and sixty-one coins were removed form the gastrointestinal tract of a schizophrenic patient during the course of hospitalization. Many of the post-1981 pennies, which consist primarily of zinc, showed severe corrosion due to their prolonged contact with acidic gastric juice. The patient presented with clinical manifestations consistent with the local corrosive as well as systemic effects of zinc intoxication and died 40 days after admission with multi-system organ failure. Tissue samples of the kidneys, pancreas, and liver obtained at autopsy revealed acute tubular necrosis, mild fibrosis, and acute massive necrosis, respectively, and contained high levels of zinc. The overall effects of zinc intoxication on the various organ systems, possible hematological derangement, and the impairment of copper absorption as well as the outcome with treatment are discussed.

Practical issues when confronting the patient who refuses blood transfusion therapy.

Caring for the Jehovah's Witness patient poses unique challenges to the medical community. Understanding the patient's viewpoint regarding the refusal of blood and blood products is an essential component in treating these patients effectively. There are currently numerous alternatives to allogeneic blood products that can be used in a variety of settings. The intent of this article is to present the beliefs of Jehovah's Witnesses regarding blood transfusion and to review the use of crystalloids, colloids, hemostatic drugs, erythropoietin, hemodilution, blood salvaging, intraoperative blood-conserving strategies, and artificial blood solutions as alternative treatments for these patients.

The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot.

BACKGROUND: Melanoma of the foot is often discussed as an uncommon tumor which, when it occurs, presents in nonwhite races. STUDY DESIGN: The tumor registry of a 650 bed community teaching hospital and the Connecticut Tumor Registry were retrospectively reviewed for the nine-year period from July 1980 to July 1989. Patient age, race, sex, incidence of misdiagnosis, and delay until definitive therapy were recorded. Tumor location, size, staging, follow-up, recurrence, and disease-free survival rates were also recorded and correlated with initial disease, stage, and misdiagnosis or delay. RESULTS: Twenty-six cases were identified at Bridgeport Hospital, and 140 cases were identified in the Connecticut Tumor Registry. Significant delay in diagnosis occurred in 68 percent of the cases from the hospital and at least 16 percent of the cases in the state tumor registry. Regardless of stage, melanoma of the foot had a worse prognosis than melanoma of the thigh and lower leg. Delays in diagnosis had no demonstrable effect on clinical outcome. CONCLUSIONS: Melanoma of the foot is not as rare as commonly suspected, and constituted 3 percent of the 4,562 melanomas reported in the state tumor registry for the nine-year period. The majority were in fair-skinned individuals, and misdiagnosis was common. It is the inherent aggressiveness of the tumor rather than the delay in diagnosis that accounts for the poor clinical outcome.

A phenothiazine derivative reduces rat brain damage after global or focal ischemia.

BACKGROUND AND PURPOSE: We previously reported that 2-(10H-phenothiazin-2-yloxy)-N,N-dimethylethanamine hydrochloride is a potent inhibitor of iron-dependent lipid peroxidation in vitro and can protect primary cultures of rat hippocampal neurons from hydrogen peroxide-induced toxicity. Because oxidants may play an important role in mediating postischemic tissue injury, we evaluated this agent in two rat models of transient cerebral ischemia. METHODS: In a model of global forebrain ischemia, 23 male Wistar rats were subjected to 10 minutes of four-vessel occlusion followed by 72 hours of reperfusion. The rats received three intraperitoneal injections of either vehicle (2% aqueous acacia) or test agent (40 mg/kg). In a model of focal stroke, 19 spontaneously hypertensive rats were subjected to 2 hours of tandem middle cerebral and ipsilateral common carotid artery occlusion followed by 24 hours of reperfusion. The rats received three intraperitoneal injections of either vehicle (2% aqueous acacia) or test agent (40 mg/kg). RESULTS: In the global model, the phenothiazine significantly protected the CA1 layer of the hippocampus, with a reduction in mean damage score from 2.1 +/- 0.3 for control rats to 1.0 +/- 0.4 for treated rats (p less than 0.05). In the transient focal stroke model, the compound reduced cortical infarct volume from 130.1 +/- 10.3 mm3 for control rats to 95.2 +/- 24.5 mm3 for treated rats (p less than 0.02). CONCLUSIONS: Although the primary mechanism responsible for the protective effect is unclear at the present time, our study is consistent with the hypothesis that oxidant-mediated lipid peroxidation may be involved in the pathophysiology of postischemic brain injury.

Alpha-glucosidase deficiency and basilar artery aneurysm: report of a sibship.

Glycogen deposition in vascular smooth muscle has been demonstrated previously in alpha-glucosidase deficiency but has not been clinically significant. Three sons of healthy, nonconsanguineous parents developed progressive proximal muscular weakness secondary to alpha-glucosidase deficiency. Each patient developed a fusiform basilar artery aneurysm, which was complicated by fatal rupture in two patients and a cerebellar infarction in the third. Postmortem examination demonstrated severe vacuolation of skeletal muscle, liver, and vascular smooth muscle with accumulation of periodic acid-Schiff-positive, diastase-sensitive material. In the surviving brother, similar glycogen deposition was demonstrated in the smooth muscle of the superficial temporal artery. Basilar artery aneurysm formation in this sibship may be a consequence of alpha-glucosidase deficiency.

Cerebellar hemangioblastoma with prominent stromal astrocytosis: diagnostic and histogenetic considerations.

A cerebellar hemangioblastoma with atypical radiologic and morphologic features is reported. On computed tomography this tumor presented as a single ring-enhancing mass in the right cerebellar hemisphere without adjacent cyst formation. It was radiologically indistinguishable from an abscess or malignant neoplasm. Postmortem examination demonstrated a circumscribed, cystic neoplasm arising in the pia at the base of a sulcus. Microscopically, the tumor contained a prominent astrocytic component that mimicked the appearance of a highly vascular astrocytoma. Hemangioblastomas with this degree of astrocytosis are unusual. They must be distinguished pathologically from both cystic astrocytoma and mixed hemangioblastoma-glioma (angioglioma).

Neurology residency training programs in the United States.

A survey of 127 neurology residency training programs (124 approved by the Accreditation Council for Graduate Medical Education; 3 by the American Osteopathic Association) in the United States indicated that 80% were sponsored by medical schools. Of the 2,700 MD neurology faculty in 1982, 3/5 were full-time. As of 1982, there were 1,300 neurology trainees, including 334 fourth-year postgraduates (PG4s); 21% were women, and 3% held DO degrees. From 1960 through 1983, about 5,000 PG4s were produced, and for 1984 through 1990 the program directors estimated that this number will be about 3,000; our own projection, however, was only 2,400.

Neurologists in the United States--past, present, and future.

Neurologists in the United States were enumerated for each year from 1935 to 1984 on two bases: board certification (including Child Neurology and Psychiatry and Neurology) and completion of PG4 neurology residency training. The annual incidence of new neurologists was calculated at less than 200 until 1970; then it rose steadily to 380 in 1980, and plateaued thereafter at 385. The estimated number of neurologists present at one time (prevalence) was 1,500 in 1950, 2,400 in 1970, 4,600 in 1980, 8,100 in 1990, and 11,000 in 2000. These numbers for total neurologists will plateau at 12,200 by about 2010, at which time the number of certified neurologists will also plateau at 9,900. Both numbers are notably less than our prior estimate of needs: 16,500 neurologists by 1990, 19,100 in 2010.

Effects of differing absolute and relative doses of progesterone and estrone on implantation and fetal survival in ovariectomized rats.

Rats were inseminated, then ovariectomized and treated with different doses of progesterone (P) and estrone (E), to determine the minimal and optimal daily doses of P and E required for implantation and fetal survival in ovariectomized rats. The minimal daily dose of P and E required for an optimal rate of implantation and fetal survival in ovariectomized rats was between 0.4 and 4.0 mg of P, and 0.1 and 1.0 microgram of E. The daily 5.0 micrograms E dose was too high to realize implantation or fetal survival when it was injected with P beginning on the day after insemination. If, however, 7 days of daily P treatment preceded the daily 5.0 micrograms E, combined with 20 mg P, delayed implantation was realized but subsequent fetal survival was not. High P doses alone did not substitute for combining E with lower P doses.

On national needs for neurologists in the United States.

Estimates of the number of neurologists needed in the United States have been widely divergent. For direct patient care needs alone in a US population of 243.5 million, the Joint Commission on Neurology (ANA-AAN) estimate was 14,000 neurologist, the Delphi Panel median (Battelle/GMENAC) 11,200, and the Advisory Panel (Battelle/GMENAC) 6,200; our review suggests a need for 12,600. Total needs for clinical neurologists including faculty were 8,400 (Advisory Panel), 14,500 (Delphi Panel), and 16,500 (ours) for respective rates of 3.44, 5.96, and 6.76 neurologists per 100,000 population.

Efficacy of sleep deprivation as an activation procedure in epilepsy patients.

The primary purpose of this article is to determine whether sleep deprivation (SD) of 24 h or longer has been demonstrated to be an effective procedure for eliciting epileptiform and/or seizure patterns in the EEG in epilepsy patients as compared with those of nonepileptics. The relevant literature is reviewed, first chronologically and then critically. Methodological problems are discussed. Although no absolutely definitive study has been done, the preponderance of evidence supports the conclusion that SD is effective in activating the EEGs of epileptics. Recommendations concerning the application of SD are offered.

Effects of a new antiestrogen, keoxifene (LY156758), on growth of carcinogen-induced mammary tumors and on LH and prolactin levels.

Keoxifene (LY156758) is a new benzothiophene-derived antiestrogen with an extremely low degree of estrogenicity. Administration of 1-20 mg/kg per day inhibited the growth of 7, 12-dimethylbenzanthracene (DMBA)-induced mammary tumors in rats. The degree of inhibition of mammary tumor growth was similar to that observed with tamoxifen treatment.

Short direct repeats flank the T-DNA on a nopaline Ti plasmid.

Crown gall disease results from the insertion of a segment of the Agrobacterium Ti plasmid, called T-DNA, into host plant nuclear DNA. We have subjected to sequence analysis the border regions of pTi T37 (ends of T-DNA) and one left T-DNA/plant DNA border fragment isolated from BT37 tobacco teratoma by molecular cloning. These sequence studies, taken together with published sequence of a right T-DNA/plant DNA border fragment, allowed us to identify the positions of left and right borders at the DNA sequence level. Comparison of left and right border regions of the Ti plasmid revealed a "core" direct repeat of 13 of 14 bases (12 contiguous) precisely at the borders of T-DNA. An extended repeat of 21 of 25 bases overlaps this core repeat. T-DNA on the Ti plasmid exhibits no longer direct or inverted repeats in the border regions, based on Southern hybridization studies. The physical structure of T-DNA differs from that of known prokaryotic and eukaryotic transposable elements but bears a structural resemblance to the prophage of bacteriophage lambda.

Effects of the interaction of the ovary with an androstane nitrile on the uterus of the rat.

The compound 17 cyano-5,16 androstadien-3 beta-ol-acetate (cyanoacetate) was considered as a promising candidate for use as a contraceptive agent, since it was reported to specifically inhibit the ovarian conversion of pregnenolone to progesterone. A preliminary study in rats indicated that this compound had unique properties that interfered with the interpretation of results concerning the decidual response. It appeared to interact with the ovaries of the animal to cause an increase in uterine weight. Because of these observations, a multiple factorial study was designed to determine whether this compound was, in fact, more uterotrophic in intact, than in spayed, psuedopregnant rats. The study demonstrated that the presence of the ovary resulted in a significantly greater uterine weight, while 2 mg progesterone daily for 10 days had no significant effect on uterine weight. Cyanoacetate (10 mg/day for 10 days) was found to increase uterine weight significantly in intact, but not spayed, psuedopregnant rats. Neither cyanoacetate (10 mg/day) nor progesterone (2 mg/day) affected ovarian weight. The data suggest that cyanoacetate is converted by the ovary from a compound with little uterotrophic activity to a material with substantial uterotrophic activity.

Maintenance of unimplanted fertilized ova in spayed rats: effects of cortisone acetate therapy during the period of embryonic diapause.

Rat dams were ovariectomized on day 3 of pregnancy and treated with corn oil (0.25 ml/day), progesterone (4 mg/day), cortisone acetate (2 or 10 mg/day), cortisone acetate (10 mg/day) plus progesterone (4 mg/day) or progesterone (4 mg/day) plus oestrone (1 microgram/day) from days 2 to 8 or 14, followed by 6 to 11 days of treatment with progesterone (4 mg/day) plus oestrone (1 microgram/day). Implantation of ova at the normal time was realized in the animals treated from day 2 with progesterone plus oestrone. Implantation of ova was only realized subsequent to progesterone plus oestrone in the dams treated with progesterone alone, cortisone acetate alone, or progesterone plus cortisone acetate, except for one animal in the latter group. Implantation of ova was not usually realized even after progesterone plus oestrone treatment in the dams treated with corn oil. Even though cortisone acetate maintained unimplanted ova in spayed rats in much the same manner as does progesterone, it was not equivalent to progesterone in efficacy or action.