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Systemic lupus erythematosus (SLE) is an autoimmune disease caused by environmental factors and loss of key proteins, including the endonuclease Dnase1L3. Dnase1L3 absence causes pediatric-onset lupus in humans, while reduced activity occurs in adult-onset SLE. The amount of Dnase1L3 that prevents lupus remains unknown. To genetically reduce Dnase1L3 levels, we developed a mouse model lacking Dnase1L3 in macrophages (conditional knockout [cKO]). Serum Dnase1L3 levels were reduced 67%, though Dnase1 activity remained constant. Homogeneous and peripheral antinuclear antibodies were detected in the sera by immunofluorescence, consistent with anti-double-stranded DNA (anti-dsDNA) antibodies. Total immunoglobulin M, total immunoglobulin G, and anti-dsDNA antibody levels increased in cKO mice with age. The cKO mice developed anti-Dnase1L3 antibodies. In contrast to global Dnase1L3−/− mice, anti-dsDNA antibodies were not elevated early in life. The cKO mice had minimal kidney pathology. Therefore, we conclude that an intermediate reduction in serum Dnase1L3 causes mild lupus phenotypes, and macrophage-derived DnaselL3 helps limit lupus. Secretion of the endonuclease Dnase1L3 by macrophages limits lupus because its loss from macrophages induces autoantibodies, including anti-double-stranded DNA antibodies. Myeloid-derived DnaselL3 limits serum lupus phenotypes. [ABSTRACT FROM AUTHOR]

The article presents a study designed to examine the practice and short-term outcomes of therapeutic mammaplasty as a treatment method for breast cancer. The authors conclude that therapeutic mammaplasty is a safe and effective treatment method compared to mastectomy or breast-conserving surgery.

Aims: We applied near-infrared-spectroscopy (NIRS) to measure absolute frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients investigated for unexplained syncope.Methods and results: Synchronized non-invasive beat-to-beat haemodynamic monitoring, ECG, SctO2 (NIRS; normal range: 60-80%), and peripheral oxygen saturation (left hand, SpO2) were applied during HUT in a random sample of patients with unexplained syncope. Tracings of 54 patients (mean-age: 55 ± 19 years, 39% male) with negative HUT, vasovagal syncope (VVS), or orthostatic hypotension (OH) were analysed. In 44 patients HUT was diagnostic, in 10 HUT was negative. Thirty-one experienced VVS. Of these, 6 had spontaneous and 25 nitroglycerin-induced syncope. Thirteen patients had orthostatic hypotension (OH). Although there was no significant change in mean-arterial pressure from baseline to 1 min before syncope or end of passive HUT phase (-1.4 ± 13.9 mmHg; P = 0.45), there was a significant fall in SctO2 during the same period (-3.2 ± 3.2%; P ≤ 0.001). Among patients who experienced syncope, a decrease in SctO2 from 71 ± 5% at baseline to 53 ± 9% (P < 0.001) at syncope was observed. During HUT, there was a significant difference in delta SctO2 between spontaneous VVS (-4.5 ± 3.0%) and negative HUT (-1.3 ± 1.9%; P  = 0.021), but not between spontaneous VVS and OH (-5.4 ± 4.2%; P = 0.65). In spontaneous VVS, progressive decrease of SctO2 was independent of mean arterial pressure decrease (P  = 0.22).Conclusions: Progressive decrease in cerebral tissue oxygenation independent of mean-arterial pressure may precede spontaneous vasovagal reflex during tilt. Patients experience syncope when SctO2 falls below 60%. These data confirm clinical utility of absolute cerebral oximetry monitoring for syncope investigation. We applied NIRS to measure frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients with unexplained syncope. In 44 of 54 patients, HUT was diagnostic. In patients with syncope, a significant SctO2-decrease was observed. Different patterns of SctO2 can be detected. [ABSTRACT FROM AUTHOR]

Background Early prediction of acute pancreatitis severity remains a challenge. Circulating levels of histones are raised early in mouse models and correlate with disease severity. It was hypothesized that circulating histones predict persistent organ failure in patients with acute pancreatitis. Methods Consecutive patients with acute pancreatitis fulfilling inclusion criteria admitted to Royal Liverpool University Hospital were enrolled prospectively between June 2010 and March 2014. Blood samples were obtained within 48 h of abdominal pain onset and relevant clinical data during the hospital stay were collected. Healthy volunteers were enrolled as controls. The primary endpoint was occurrence of persistent organ failure. The predictive values of circulating histones, clinical scores and other biomarkers were determined. Results Among 236 patients with acute pancreatitis, there were 156 (66·1 per cent), 57 (24·2 per cent) and 23 (9·7 per cent) with mild, moderate and severe disease respectively, according to the revised Atlanta classification. Forty-seven healthy volunteers were included. The area under the receiver operating characteristic (ROC) curve (AUC) for circulating histones in predicting persistent organ failure and mortality was 0·92 (95 per cent c.i. 0·85 to 0·99) and 0·96 (0·92 to 1·00) respectively; histones were at least as accurate as clinical scores or biochemical markers. For infected pancreatic necrosis and/or sepsis, the AUC was 0·78 (0·62 to 0·94). Histones did not predict or correlate with local pancreatic complications, but correlated negatively with leucocyte cell viability ( r = -0·511, P = 0·001). Conclusion Quantitative assessment of circulating histones in plasma within 48 h of abdominal pain onset can predict persistent organ failure and mortality in patients with acute pancreatitis. Early death of immune cells may contribute to raised circulating histone levels in acute pancreatitis. [ABSTRACT FROM AUTHOR]

A detailed study was made of herpes simplex virus type 1 (HSV-1) isolates from an immunocompromised patient whose infection became resistant to acyclovir (ACV) during a prolonged course of oral treatment. Three HSV isolates and 33 virus clones derived from them were characterised. The development of clinical resistance correlated with the emergence of thymidine kinase (TK) defective strains. The ACV-sensitive strains studied contained a small proportion of insensitive virus. The resistant isolate contained 0.6% of TK-positive virus which was sensitive to a relatively low concentration of ACV. [ABSTRACT FROM AUTHOR]

Background Surgical reconstruction following pancreaticoduodenectomy ( PD) is associated with significant morbidity and mortality. Because of great variability in definitions of specific complications, it remains unclear whether there is a difference in complication rates following the two commonest types of reconstruction, pancreaticogastrostomy ( PG) and pancreaticojejunostomy ( PJ). Published consensus definitions for postoperative pancreatic fistula ( POPF) have led to a series of randomized clinical trials ( RCTs) uniquely placed to address this question. Methods A literature search was carried out to identify all RCTs comparing postoperative complications of PG versus PJ reconstruction following PD published between January 1995 and December 2013. Pooled odds ratios ( ORs) with 95 percent confidence intervals (c.i.) were calculated using fixed-effect or random-effects models. Results In total, seven RCTs with 1121 patients were included. Four of these trials applied definitions as published by the International Study Group on Pancreatic Fistula ( ISGPF). Using ISGPF definitions, the incidence of POPF was lower in patients undergoing PG than in those having PJ ( OR 0·50, 95 per cent c.i. 0·34 to 0·73; P < 0·001). Using definitions applied by each individual study, PG was associated with significantly lower rates of POPF ( OR 0·51, 0·36 to 0·71; P < 0·001), intra-abdominal fluid collection ( OR 0·50, 0·34 to 0·74; P < 0·001) and biliary fistula ( OR 0·42, 0·18 to 0·93; P = 0·03) than PJ. Conclusion Meta-analysis of four RCTs based on ISGPF criteria, and seven RCTs using non-standard criteria, revealed that PG reduced the incidence of POPF after PD compared with PJ. [ABSTRACT FROM AUTHOR]

Foreign body ingestion in children is common. Most items pass spontaneously, however rarer cases may result in obstruction and or perforation. Ingestion of multiple magnetic items can be more troublesome, as a consequence of the ability of the items to attract across different sections of bowel, or by coalescing to form a larger foreign body. Very few cases of foreign body ingestion have led to the presentation of a complicated Meckel's diverticulum. We present of a case of an adolescent boy with intestinal obstruction secondary to multiple magnetic foreign body ingestion and sequestration within a Meckel's diverticulum. [ABSTRACT FROM AUTHOR]

The article provides information on the complications and follow-up after the pancreas-preserving total duodenectomy (PPTD) for duodenal polyps. It is concluded that the morbidity of PPTD is the same with partial pancreatoduodenectomy but the PPTD preserves the whole pancreas and decreases the number of anastomoses.

The article discusses a study on the assessment of using carbohydrate antigen 19.9 (CA19.9) levels to select patients for laparoscopic ultrasonography (L-LUS). The authors note that L-LUS may be useful in patient selection for surgery to resect peripancreatic malignancy in addition to contrast-enhanced computed tomography (CE-CT). Results of the study reveal that CA19.9 effectively increased resection rates and reduced unwanted laparotomies.

Background: Little is known of the variations of the heart rate during spontaneous cardioinhibitory neurally-mediated syncope. Their knowledge has both academic and practical implications for the optimization of rate drop response (RDR) pacing mode. [ABSTRACT FROM PUBLISHER]

Focuses on surgical risk score, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth predictors POSSUM (p-POSSUM) in higher-risk surgical patients. Risk-adjusted surgical audit; Absence of surgeon-related bias.

Aims Left ventricular (LV) and biventricular (BiV) pacing are potentially superior to right ventricular (RV) apical pacing in patients undergoing atrioventricular (AV) junction ablation and pacing for permanent atrial fibrillation. [ABSTRACT FROM PUBLISHER]

This study investigated the ability to minimize pace polarization artefacts (PPA) by adjusting the post-stimulus pulse duration of a tri-phasic stimulation pulse. Adjustment of the stimulation pulse was enabled by downloading special study software into an already implanted pacemaker. Tests were performed in a total of 296 atrial leads and 311 ventricular leads. Both chronic and acute leads were included in the study. Statistically significant differences were found in the initial PPA (without any adjustment of the stimulus pulse) between atrial and ventricular leads. In addition, significant differences were observed among various lead models with respect to changes over time in the initial ventricular PPA. Successful PPA reduction was defined as a reduction of the PPA below 0.5 mV for atrial leads and below 1 mV for ventricular leads. Results show a success rate for ventricular and atrial PPA reduction of 97.8% and 98.7%, respectively. Threshold tests showed that after reduction of the PPA loss of ventricular capture can be reliably detected. However, atrial threshold tests showed many false positive evoked response detections. In addition, unexpectedly high evoked response amplitudes were observed in the atrium after reduction of the PPA. Results from additional measurements suggest that these high atrial evoked response amplitudes come from the influence of the input filter of the pacemaker. [ABSTRACT FROM PUBLISHER]

Discusses that survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status. Background of the object to be examined; Methods used in the study; Results of the study.

Performs an electronic and manual search for articles on the surgical treatment of pancreatic cancer. Major areas of advancement; Groups at high risk of developing pancreatic cancer; Improvement in the methods of staging pancreatic cancer for resection; Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy; Suggestion that high-volume centers improve the results of surgery for all outcome measures including long-term survival.

Evaluates the outcome of major resection for chronic pancreatitis in patients with or without vascular involvement. Evidence showing that resection for severe chronic pancreatitis in patients with vascular complications is hazardous and is associated with an increased mortality rate; Need for vascular assessment to be included in the routine follow-up of patients with chronic pancreatitis.

Background: The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis. Methods: Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied. Results: The median age was 60·5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62·5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7·9 to 10·1) and there were 21 deaths (32·8 per cent). Twenty-eight patients (43·8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72·1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0·240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0·001). Survivors had significantly longer times to surgery than those who died (P = 0·038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0·001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0·042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0·031). Conclusion: Advanced age and increasing APACHE Il score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy. [ABSTRACT FROM AUTHOR]

Describes a new operation, duodenum- and spleen-preserving total pancreatectomy. Importance of total pancreatectomy in patients with advanced chronic pancreatitis in whom partial resection has failed and in those with end-stage pancreatic function; Analysis of pertinent topics and relevant issues; Implications on studies of surgery.

SUMMARY In order to improve the efficacy of endoscopic surveillance of Barrett's esophagus, markers of neoplastic progression in addition to dysplasia are required. The aim of the present study was to assess TP53 mutational analysis as a method of identifying patients with Barrett's esophagus who are at greatest risk of adenocarcinoma, for whom endoscopic surveillance is most appropriate. TP53 mutational analysis was initially performed on premalignant and malignant tissue from 30 patients undergoing esophagectomy for adenocarcinoma, and on premalignant biopsies from 48 patients participating in a Barrett's surveillance program. Surveillance patients were followed up endoscopically and histologically for a median of 5 years following TP53 assessment. Mutational analysis was performed by single-strand conformation polymorphism analysis and direct DNA sequencing. TP53 mutations were detected in 10 of 30 esophageal adenocarcinomas, and were more common in well-differentiated carcinomas. An identical TP53 mutation was detected in carcinoma and adjacent dysplasia. Two patients with premalignant Barrett's esophagus had TP53 mutations and one of these patients developed adenocarcinoma on follow up whilst the other has not yet progressed beyond metaplasia. No patient without TP53 mutation developed high-grade dysplasia or adenocarcinoma. TP53 mutations are detected in 33% of esophageal adenocarcinomas and in 4% of premalignant Barrett's esophagus in patients undergoing endoscopic surveillance. TP53 mutation can be detected before the development of high-grade dysplasia or carcinoma, and may be useful in stratifying the risk of adenocarcinoma in patients with Barrett's esophagus. [ABSTRACT FROM AUTHOR]

Aim Left atrial isomerism (LAI) is an uncommon congenital heart disease, which is combined with a range of intracardiac abnormalities. Atrial arrhythmia is common in LAI. We hypothesized that permanent pacing will decrease arrhythmia recurrence in adult patients with LAI. Methods and results Patients with LAI and permanent pacing were identified from the Royal Brompton Adult Congenital Heart Database. Hospital records were reviewed, and patients' current status was assessed with clinic reviews including standard and Holter ECGs, and transthoracic echocardiograms. Conclusion Adults with LAI benefit from pacemaker implantation, which reduces recurrence of supraventricular tachycardia and maintains atrioventricular synchrony. Future studies need to determine the preferred pacemaker mode and optimal timing for pacing. [ABSTRACT FROM PUBLISHER]

Background: Comparative surgical audit is becoming increasingly important although it is fraught with difficulties due to risk-adjusted analysis. Methods have been proposed to solve this problem and allow meaningful comparison of patient outcome. None has been described without faults, making such comparison flawed or overtly complicated. An alternative risk scoring system incorporating the Confidential Enquiry into Perioperative Deaths (CEPOD) grade, the American Society of Anesthesiologists (ASA) grade and the British United Provident Association (BUPA) operative grade was formulated and assessed. Methods: This was a prospective audit of 4308 patients admitted under the care of three surgeons between May 1997 and October 1999, creating an initial data set of 3144 procedures with 134 deaths. Each procedure was allocated a score on the basis of the CEPOD, BUPA and ASA grade. The Surgical Risk Scale (SRS) was devised by adding together the values of the three variables, which generated a scale ranging from 3 to 14. Multivariate logistic regression analysis involving the three variables and univariate analysis of the SRS score were undertaken. Receiver–operator characteristic and calibration curves were formulated. This process was validated on another data set (2780 patients) derived from all admissions to the same surgeons between November 1999 and December 2000. Results: Univariate logistic analysis of the SRS score revealed it to be significantly predictive of death (β = 0·84, P < 0·001); it did not overpredict mortality for low-risk procedures. Conclusion: The SRS is easy to use, formulate and interpret, and provides an accurate prediction of death in general surgical patients across the entire risk spectrum. [ABSTRACT FROM AUTHOR]

Background: Multiple organ dysfunction syndrome secondary to systemic leucocyte activation is the major cause of death following an attack of acute pancreatitis. Although plasma levels of interleukin (IL) 8 are known to be raised in acute pancreatitis, levels of other CXC chemokines such as growth-related oncogene (GRO) α and epithelial neutrophil-activating protein (ENA) 78, which are also potent neutrophil chemoattractants and activators, have not been measured. Methods: Timed plasma samples were obtained from 51 patients with acute pancreatitis, 27 with a severe attack and 24 with mild disease according to the Atlanta classification. Samples were analysed to determine levels of C-reactive protein (CRP), IL-8, GRO-α and ENA-78. Results: Plasma levels of IL-8, GRO-α and ENA-78 were increased in patients with severe as opposed to mild acute pancreatitis as early as 24 h following disease onset. Using cut-off levels of 7 pg/ml for IL-8, 70 pg/ml for GRO-α and 930 pg/ml for ENA-78, peak levels within the first 24 h of admission had an accuracy of 81, 71 and 87 per cent respectively in predicting the severity of an attack of acute pancreatitis. Conclusion: In patients with severe acute pancreatitis plasma levels of GRO-α and ENA-78 were raised in addition to those of IL-8, suggesting that all three chemokines are involved in the inflammatory response in this condition. [ABSTRACT FROM AUTHOR]

No Abstract [ABSTRACT FROM PUBLISHER]

Background Though vasovagal syncope probably does not directly cause death, it is often associated with severe trauma and, when recurrent, significantly impairs the patient's quality of life. While drug therapy for vasovagal syncope is still controversial, recently two randomized studies revealed the efficacy of dual-chamber pacemaker implantation in decreasing recurrences in very symptomatic patients. However, since both studies were not placebo-controlled, the benefits observed might have been due to the placebo effect of the pacemaker. Aim of the study The aim of the vasovagal Syncope and pacing (Synpace) trial, a multicentre, prospective, randomized, double-blind, placebo-controlled trial, is to ascertain whether, in patients suffering from recurrent vasovagal syncope, the implantation of a dual-chamber pacemaker with rate drop response algorithm programmed to ON, will reduce syncope relapses compared with the implantation of a pacemaker programmed to OFF. Moreover, in order to evaluate the role of the haemodynamic response during tilt-induced syncope in identifying those patients who will benefit most from pacemaker implantation, enrolled patients will be divided into two groups on the basis of their haemodynamic behaviour during tilt-induced syncope: group 1, asystolic response (development of asystole >3 s), and group 2, mixed response (development of bradycardia <60 bpm, without asystole >3 s). The head-up tilt testing protocol will consist of 20 min at 60 degrees without drug potentiation, followed by 15 min at the same inclination after 400 μg of sublingual nitroglycerin. Results from the two groups will be analysed both separately and globally. The primary clinical endpoint of the study will be syncope. Inclusion and exclusion criteria To be enrolled, patients will have to meet the following criteria: at least six syncopal episodes in the patient's lifetime; positive head-up tilt testing with asystolic or mixed response; at least one syncope recurrence following a positive head-up tilt test. The following constitute exclusion criteria: non-vasovagal syncope; other indications for pacing. Sample size We hypothesize a risk of syncope recurrence of 70% after one year, and we estimate that — owing to the placebo effect alone — pacemaker will produce a 20% decrease in risk, which corresponds to a 50% risk of recurrence after one year, in those patients randomized to ‘pacemaker OFF’. We calculate conservatively a risk decrease of 60% in patients with ‘pacemaker ON’. This implies a 10% incidence of syncope recurrence after one year, vs 50% in patients with ‘pacemaker OFF’. Fifty patients will need to be enrolled in the study: 25 patients for each group. [ABSTRACT FROM PUBLISHER]

Background This paper presents a consecutive series of permanent pacemakers (PPM) implanted via the femoral vein in patients with contraindications to pacing systems via the superior vena cava (SVC). The femoral vein approach is a less invasive and feasible alternative to epicardial lead placement. Methods Twenty-seven patients had femoral pacemakers inserted. Indications for femoral vein pacemaker insertion were: SVC/subclavian obstruction (12 patients, 44·4%), previous infection in SVC leads (four patients, 14·8%), mastectomy and/or radiotherapy to chest (four patients, 14·8%), multiple leads in SVC (two patients, 7·4%), recurrent erosion (two patients, 7·4%), abnormal anatomy (one patient, 3·7%), painful pacemaker pocket (one patient, 3·7%) and burns (one patient, 3·7%). Fifty-one leads, 25 atrial and 26 ventricular, were inserted. The majority of leads were active fixations (96% of atrial leads and 85% ventricular leads). Results During a mean follow-up of 36·5 months (range 0·9–116·5), six additional unplanned procedures were performed in four patients. Atrial lead displacement occurred in five leads (20%). There were no ventricular lead displacements. In two patients, box revision for pre-erosion was required. One patient had persistent pain at the site of abdominal pacemaker generator. Infection, thromboembolic events, thromophlebitis, evidence of lower limb venous occlusion and lead fracture did not occur. Conclusion Femoral vein PPM are a simple and feasible alternative in patients in whom the SVC approach is contraindicated. [ABSTRACT FROM PUBLISHER]

Head-up tilt testing potentiated by sublingual nitroglycerin (NTG), advocated by an Italian group, is a simple and safe but still not a standardized, diagnostic tool for the investigation of syncope. In fact, owing to its rapid spread, the original protocol received, often arbitrarily, many subsequent modifications. We now define the best methodology of the test on strictly evidence-based criteria as: stabilization phase of 5 min in the supine position;passive phase of 20 min at a tilt angle of 60 degrees;provocation phase of further 15 min after 400 μg NTG sublingual spray. Test interruption is made when the protocol is completed in the absence of symptoms, or there is occurrence of syncope, or occurrence of progressive (>5 min) orthostatic hypotension. We intend that this protocol, named by us as ‘The Italian Protocol’, will be accepted as the standard methodology of the tilt test potentiated by sublingual nitrates. [ABSTRACT FROM PUBLISHER]

Atrioventricular junctional (AVJ) catheter ablation followed by pacemaker implantation is now widely accepted for patients affected by paroxysmal atrial fibrillation (PAF) not controlled by antiarrhythmic drugs. However, few data exist on its indications, optimal methodology and complications. Therefore a study group examined current practice in Europe and North America, using a questionnaire, followed by a Study Group Meeting to discuss the results. Based upon this, class I, class II and class III indications were proposed. Class I indications (for which general agreement existed) include drug-refractory PAF, correlating with important symptoms, the bradycardia–tachycardia syndrome already treated with a pacemaker, and continued PAF. Large differences exist in the current methodology, but consensus was reached on the technical approaches of right and left-sided AVJ ablation, and on the timing of pacemaker implant in relation to ablation. No complete agreement was reached on technical features such as catheter choice and heparin use. The recommended pacing mode was DDDR with mode switching. [ABSTRACT FROM PUBLISHER]

Autoantibodies were looked for by immunofiuorescence (IFL) in seventy-seven cases of infectious mononucleosis (IM) at the onset of symptoms and on recovery, to determine the time of appearance, duration and range of these responses, and to correlate them with serum immunoglobulin and EB virus antibody titres. Antibodies to lymphocyte membrane demonstrated by IFL, now identified with lymphocytotoxins, were present in 46% of patients in the acute stage, persisting for less than 7 weeks. Antibodies to smooth muscle (SMA) or to contractile fibres in other tissue cells including human thyroid and rat hepatocytes, were present in over 70% of cases, some being entirely of IgM class. The highest titres occurred soon after onset and these antibodies also disappeared during convalescence. By contrast ANA, mitochondrial, microsomal and reticulin antibodies, also thyroid and gastric organ-specific reactivity were seen only occasionally owing to the young age group of the patients. In individual cases there was no correlation between the appearance of lymphocyte antibodies and SMA, or between these and the EB virus antibody titres. [ABSTRACT FROM AUTHOR]

The benefits of dual (DDD) over single chamber pacing (VVI) have been demonstrated in haemodynamics, exercise capacity, quality of life and reduced complications in atrioventncular block and sick sinus syndrome.The literature was reviewed to provide complication rates for dual and VV1 pacing. Cost calculations were based on United Kingdom 1991 prices. Over a 10-year period, a computer model calculated the incidence and prevalence of atrial fibrillation, stroke, permanent disability, heart failure and mortality in six patient categories: sick sinus syndrome paced VVI, sick sinus syndrome upgraded to DDD, sick sinus syndrome paced DDD from outset, atrioventricular block paced VYI and those upgraded to DDD and atrio ventricular block paced initially DDD. Calculations were based on intention to treat.The 10 year survival with DDD vs YVI pacing was 71% vs 57% in sick sinus syndrome and 61% vs 51%, respectively, in atrioventricular block. In both indications the prevalence of heart failure in the 10 year survivors was 600 lower with DDD pacing. In sick sinus syndrome patients paced VVI, 36% had severe disability while only 8% experienced this with DDD pacing. For atrioventricular block the figures were, respectively, 22% vs 3%. The difference in 10 year cumulative cost between VVI and DDD is 13 times the purchase price of a VVI pulse generator for sick sinus syndrome and 7 times for atrioventricular block. In the third year after implantation the cumulative costs of DDD were lower than for VVI for both indications.Dual chamber pacing for both indications, sick sinus syn drome and atrioventricular block, is both clinically and cost effective. [ABSTRACT FROM PUBLISHER]

Simultaneous intra-radial and non-invasive (Finapres, Ohmeda) blood pressures were compared during prolonged head-up tilt, in eight patients (mean age 49 years) with malignant vasovagal syncope. Twelve tilts were performed, of which eight resulted in vasovagal syncope. The mean bias (difference between Finapres and intra-arterial pressures) for systolic pressure was +0.7 mmHg (standard deviation 11.3 mmHg) and for diastolic pressure was +5.4 mmHg (standard deviation 7 mmHg). The within-tilt precision (standard deviation of the bias) of the non-invasive measurements varied between 2.9–12.4 mmHg (median 4.5 mmHg) for systolic comparisons, and 1.6–8.4 mmHg (median 4.4 mmHg) for diastolic comparisons. In all but one tilt highly significant positive increases in both systolic (median 7.1 mmHg) and diastolic bias (median 81 mmHg) occurred on tilt with respect to resting pre-tilt levels. Independent of the absolute level of agreement, the non-invasive measurements followed changes in intra-arterial pressure closely, with 89% of beat-to-beat changes in systolic pressure, and 95% of beat-to-beat changes in diastolic pressure followed to within ±2 mmHg. This study suggests that the Finapres is well suited for use during diagnostic tilt testing, demonstrating an acceptable within-tilt precision and closely following pressure changes during vasovagal syncope. [ABSTRACT FROM PUBLISHER]

We reviewed 322 patients with recurrent syncope between 1984 and 1988. Investigation included limited intracardiac electrophysiological study in all cases with programmed extra-stimulus studies in 48 cases. In 93 patients (29%), all investigations were normal, (including negative extrastimulus in 30). In the other 229 cases syncope was explained by AV-block (n = lll, 34%), sinus node disease (n = 68, 21%), carotid sinus syndrome (n = 32, 10%) and inducible sustained tachyarrhythmia (n=18, 6%). Prolonged 60° head-up tilt was performed in 71 out of 93 patients with unexplained syncope, and reproduced vasovagal syncope and presenting symptoms in 53 (75%), or 16% of the whole population reported. These patients were diagnosed as having malignant vasovagal syndrome. Positive tilts were significantly less common in a group of 27 subjects of similar age without a history of syncope (7%), and a random sample of 37 patients with atrioventricular block (n= 16), sick sinus syndrome (n= 18) and inducible tachy arrhythmia (n = 3) (19%, 11% andO% respectively, P < 0.01). From this retrospective review it appears, therefore, that tilt testing is a valuable provocative tool for vasovagal syncope and may reduce the number of syncopal patients that remain undiagnosed, although these early observations do not allow an exact appraisal of the sensitivity and specificity of the tilt test. [ABSTRACT FROM PUBLISHER]

Objective: The aim was to determine the exact sequence of hormone changes during the progression of fluid retention in a canine model of “congestive cardiac failure” induced by rapid right ventricular pacing, and during recovery when pacing is stopped. Methods: Rapid ventricular pacing at a rate of 250 pulses·min−1 was used in six mongrel dogs with implanted right ventricular pacemakers. Right heart haemodynamics were measured by means of Swan Ganz catheterisation, allowing flow measurement by thermodilution and pressure measurement by external manometry. Plasma renin activity, arginine vasopressin, and atrial natriuretic factor were assayed on venous blood samples by radioimmunoassay. Noradrenaline was assayed by high pressure liquid chromatography. Results: The onset of rapid pacing was accompanied by a fall in cardiac output and a rise in pulmonary arterial, pulmonary capillary wedge, and right atrial pressures. Noradrenaline and atrial natriuretic factor rose. Plasma renin activity showed an initial fall followed by a rise, and arginine vasopressin was unchanged in the first 8 h. When rapid pacing was continued for a further 35 d, clinical signs of fluid retention appeared by day 28, by which time cardiac output had fallen, and central pressures risen further. Atrial natriuretic factor peaked at around 14 d whereas plasma renin activity, arginine vasopressin, and noradrenaline tended to reach a plateau at about d 20 and then to show further increases as clinical signs of fluid retention appeared; this was most marked with plasma renin activity. Cessation of pacing at d 35 caused a rapid reversal (increase) of cardiac output but a more gradual reversal (decrease) of right heart pressures over 5 d; only wedge pressure returned to base line. Arginine vasopressin and plasma renin activity fell rapidly to around 40% of the final pacing levels and reached basal values after 8 h and 48 h respectively. Noradrenaline fell after 8 h and reached basal levels in 5 d. Atrial natriuretic factor fell quickly by 60% after 8 h but remained above basal levels for 5 d. At the end of pacing, body weight fell rapidly in conjunction with a large diuresis. Conclusions: These findings are compatible with a major role of one or more of renin, vasopressin, and noradrenaline in the pathophysiology of the fluid retention of heart failure; the manifestations are not counteracted by the rise in atrial natriuretic factor. [ABSTRACT FROM PUBLISHER]

Baroreflex sensitivity was measured by the heart rate response to the transient rise in blood pressure induced by phenylephrine, in 11 patients with carotid sinus syndrome, 6 patients with sick sinus syndrome and nine age and blood pressure matched controls. Patients with carotid sinus syndrome were divided into those with a hypersensitive carotid sinus reflex manifest as sinus arrest (n=9) and those with a reflex manifest as atrioventricular block (n=2). The mean gain of the baroreflex sensitivity was significantly increased (p<0.001) in patients with carotid syndrome manifest as sinus arrest (12.7±5.1 ms·mmg−1) compared to that in patients with sick sinus syndrome (3.8±2.6 ms·mmHg−1) and controls (4.2±2.1 ms·mmHg−1). Patients with carotid sinus syndrome manifest as atrioventricular block did not have increased baroreflex sensitivity measured by their sinus node response (2.1 ±0.5 ms·mmHg−1). There was significant correlation (p<0.001) between the corrected carotid sinus inhibitory response to carotid sinus massage and the measurement of baroreflex sensitivity in the carotid sinus syndrome patients. Patients with carotid sinus syndrome manifest as reflex sinus arrest have an increased gain in baroreflex sensitivity for their age, which is not seen in patients with symptomatic sinoatrial disease. This study provides further evidence of a different mechanism of bradycardiac symptoms in patients with carotid sinus and sick sinus syndromes. [ABSTRACT FROM PUBLISHER]

Assessment of the carotid sinus baroreceptor control of pulse interval has been made, by means of neck suction, in 10 patients with a clinical diagnosis of the carotid sinus syndrome (CSS). Results have been compared with 16 age-matched control patients. The mean gain in the CSS patients was 11.64±2.51 ms·mmHg−1, whereas the mean gain in the control patients was 3.61±0.68 ms·mmHg−1 (p<0.02). There was a significant correlation (p<0.01) between the degree of cardiac slowing, following carotid sinus massage, and the gain, following neck suction, in the CSS patients. Abnormality of the carotid sinus baroreceptor control of heart rate is confirmed in these patients and neck suction is an useful method of investigation of this syndrome. [ABSTRACT FROM PUBLISHER]

Two hundred and forty four patients underwent either simultaneous bilateral inguinal hernia repair (n = 122) or unilateral inguinal hernia (n = 122) repair at a general hospital between January 1971 and December 1981. The two groups of patients were matched for age and sex. Both groups had a similar overall incidence of post-operative complications and in both groups the duration of post-operative stay and duration of operating time were similar. Chest infections developed in 12 patients after bilateral repair and in 3 patients after unilateral repair (P less than 0.02). All patients were assessed prospectively from 4 to 15 years after operation, when no significant difference in the number of recurrent hernias was found. Our results suggest that simultaneous bilateral inguinal herniorrhaphy is economical in terms of both operating time and duration of hospital stay, and that this economy is not bought at a cost of increased short term morbidity or long-term recurrence rate. [ABSTRACT FROM PUBLISHER]

Although recognized since the 1930s, slow infections have only recently received considerable attention. There are three types, group A (related to the type C RNA viruses), group B (bizarre agents such as scrapie and kuru) and group C (viruses such as measles which normally produce acute infections but which are behaving here in an unusual fashion). These viruses are only united in that they produce disease with excessively long incubation periods. Many slow infections result in neurological diseases and these will be discussed, together with some possible explanations of their action. [ABSTRACT FROM PUBLISHER]

Any approach towards elucidating the aetiology of an ill defined disease such as 'epidemic neuromyasthenia' has to be a comprehensive and wide-ranging one. Although viruses must be strong candidates, by reason of their ubiquity, this need not necessarily be the case and we have recently seen the onset of Legionnaires' disease as a new entity caused by a bacterium. We do not always recognize that a particular virus may affect the entire community and that the patient seen in hospital may represent only the tip of the submerged iceberg and that, in closed communities more of the iceberg will be seen. Silent viral epidemics are probably frequent and may only be recognized in retorspect. As an example the recent epidemic with adenovirus type 7 will be alluded to. Possible variations in virus and, to a lesser extent, in the host which could modify the course of an individual infection are discussed. [ABSTRACT FROM PUBLISHER]

In a randomized, controlled clinical study, dextran-70, warfarin, or low-dose heparin were administered to patients undergoing total hip replacement on one surgical unit in an attempt to prevent deep venous thrombosis and pulmonary embolism. Calf vein thrombosis was detected by the 125I-fibrinogen uptake test. None of the methods prevented calf vein thrombosis (dextran-70, 51%; warfarin, 58-6%; heparin, 52-6%). Pulmonary embolism was completely prevented in patients treated with warfarin but occurred in 4% of patients treated with dextran-70 and 15-5% of those treated with low-dose heparin. The incidence of complications of therapy was small and comparable in each group. It is suggested that calf vein thrombosis is a frequent and in itself a non-serious complication of total hip replacement surgery and that emphasis might be placed more usefully on prevention of pulmonary embolism. [ABSTRACT FROM AUTHOR]