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Troponin-T was measured in patients with chest pain and negative creatine phosphokinase-MB isoenzymes. Patients with elevated troponin-T had a significantly greater risk of cardiac events over the next 6 months than patients with normal troponin-T.

Determining the status of peripheral innervation can be difficult in certain patients. The phenomenon of skin wrinkling has been shown to be a reliable indicator of gross nerve function. This study examines the effect of various water temperatures on the time to skin wrinkling. The optimal temperature for testing hands is 40 degrees C and skin wrinkling should occur in approximately 3.5 minutes.

In examining the effects of corticosteroids on hematopoiesis in vitro, we observed that results were highly dependent on the lot of commercial fetal calf serum (FCS) utilized. We hypothesized that this variability correlated with the picogram (pg) level of endotoxin contaminating the FCS. Randomly obtained commercial lots of FCS contained 0.39 to 187 pg/ml of lipopolysaccharide (LPS). Standard FCS concentrations in hematopoietic precursor proliferation assays (granulocyte-marcrophage colony forming units [CFU-GM]) resulted in final LPS levels as high as 40 pg/ml. LPS (2-5 pg/ml) added to essentially endotoxin-free cultures, induced human mononuclear cell release of interleukin (IL)-1, IL-6 and granulocyte colony stimulating factor (G-CSF). Lots of FCS induced the release of IL-1, IL-6, and G-CSF from human mononuclear cells and the release of these factors correlated with the level of contaminating LPS. Human bone marrow CFU-GM proliferation, in response to granulocyte-macrophage colony stimulating factor (GM-CSF), positively correlated with the level of LPS contaminating the FCS and the FCS-induced release of IL-6 from mononuclear cells. CFU-GM proliferation of human bone marrow cluster of differentiation (CD) 34+CD14-cells were not affected by the presence of endotoxin. These data suggest that LPS at 2-5 pg/ml may induce bone marrow accessory cell release of hematopoietic growth factors, thus altering proliferative response of hematopoietic precursors and confounding the study of exogenously added cytokines to culture systems.

Patient-focused care is the redesign of patient care so that personnel and resources are organized around the patient instead of departments. The reasons are many but usually involve cost reductions and improvement in the customer's perception of quality. Goals for this process include grouping patients by diagnosis, decentralizing services, and cross-training staff. The respiratory care practitioner is well prepared to fit into the patient-focused care model. Recent surveys show the impact of hospital restructuring on respiratory care to be rather positive.

The Texas newborn screening for congenital hypothyroidism detects 90 to 150 cases each year; no affected babies have been missed. Babies dismissed from the hospital less than 24 hours after birth have a greater chance of an abnormal screening test, but most of the reported values reflect physiologic responses to birth and do not represent true hypothyroidism. A few represent thyroid disease. The astute physician recognizes a truly significant value; the unwary ignores a significant report and places the patient and himself at risk.

The authors present a follow-up of the Austin bunionectomy using a single 2.7-mm American Society of Internal Fixation (ASIF) screw. At a mean 5-year follow-up, 45 feet in 32 patients were evaluated with information from clinical examination, radiographic data, and responses to a patient questionnaire. When compared to the 18-month follow-up, good reduction of the intermetatarsal and the hallux abductus angle were maintained. Clinical findings, including the first metatarsophalangeal joint range of motion and hallux purchase power, remained acceptable, and a small number of new transfer lesions were noted. Patient satisfaction with appearance and overall satisfaction with the procedure remained excellent-to-good in 96% of the procedures.

Background: Erythema nodosum (EN) is a condition characterized by the presence of painful erythematous nodules on the pretibial aspects of the lower extremities. EN is thought to be a local inflammatory, immune-mediated reaction to a number of systemic antigenic stimuli. This condition is noted most often in women between menarche and menopause and is associated with certain drugs, infections, and pregnancy. However, no reports in the literature describe EN as a result of streptococcal infection during pregnancy., Case: A 21-year-old, white woman, G(3)P(0020), presented at 13 weeks gestation with a 2-week history of erythematous, tender lesions on the pretibial aspects of both legs consistent with EN. The patient reported having had a "flu-like" illness at the same time the lesions developed. The "flu" symptoms resolved within 10 days without medical intervention, but the lesions on her legs persisted. An initial antistreptolysin-O (ASO) titer was elevated at 960 Todd units (normal values: preschool and adults <85; school-age and young adults <170). Six days later, she presented to the emergency department with complaints consistent with a urinary-tract infection. She was empirically treated with a 10-day course of amoxicillin, 500 mg t.i.d. Although the patient was treated with amoxicillin for a presumed urinary-tract infection (which was culture-negative), the lesions resolved after her completion of the antibiotics. Twelve weeks later, a repeat ASO was within normal limits. The EN lesions did not recur., Conclusion: Although many etiologic factors are identified as causes of EN, the condition is usually self-limiting, requiring only minimal supportive measures until it resolves. A careful history should be obtained and a physical examination performed to exclude other causes. If a recent streptococcal infection is identified or presumed, a 10- to 14-day course of antibiotics is warranted.

The importance of maintaining or restoring the size of the protein pool remains the primary objective of nutrition therapy for the hospitalized patient. Also, newer nutritional markers are needed that identify malnourished patients and effectively monitor nutritional intervention on the patient's nutritional status. To do this, one must assess protein pools in an effective manner. Newer protein markers must have a short biologic half-life and reflect protein deficiency with decreasing serum concentrations. The proteins discussed offer unique opportunities for investigating malnutrition in the hospital and clinic setting. More studies to elucidate the effects that diseases and drugs have on these proteins in particular patient subpopulations are needed. Additional methods also need to be developed to make assays for SMC and interleukin cost effective in hospital or clinic settings. In the next decade, certainly more research will be undertaken on these promising new nutritional markers.

An end-to-end anastomosis was done in the center of a 5-cm devascularized jejunal segment in 5 control laboratory rabbits and 14 experimental rabbits. A second group consisted of 5 control animals and 11 experimental animals having end-to-end jejunojejunostomy in the center of a 10-cm devascularized jejunal segment. In the experimental animals, the anastomosis was wrapped circumferentially by a vascularized omental pedicle. Anastomotic leaks or fistulas developed in five 10-cm controls (100%), five 5-cm controls (100%), nine 10-cm omental wraps (82%), and four 5-cm omental wraps (29%). The remaining animals had strictures of various degrees. Injection of methylene blue into the omental vessels showed perfusion to the mucosa from the omentum. The difference between the 10-cm segment and the 5-cm segment indicates some limitation to the available blood flow from the omentum. The anastomotic stricturing was due to ischemic injury before reperfusion by ingrowth of omental vessels. A vascularized omental pedicle wrap can augment blood flow; however, the time required for neovascular ingrowth allows ischemic mucosal injury if there is no other available blood supply.

Hyperbaric oxygen has been shown to improve oxygen tension and promote wound healing. We did a pilot study in which we created ischemic jejunal segments measuring 3, 6, and 9 cm, 10 of each length, in 30 rats. Half of the rats were given hyperbaric oxygen at 100%, 30 psi, for 90 minutes twice daily for 7 days to determine whether hyperbaric oxygen therapy could overcome the ischemic intestinal injury and prevent ischemic necrosis. In the rats with 6- and 9-cm ischemic segments, no difference was seen between the hyperbaric oxygen and control groups. Of the rats with 3-cm ischemic segments, ischemic infarction of the bowel developed in 40% of the hyperbaric oxygen group and 100% of the controls (P = 0.167, Fisher's Exact Test). We then created 3-cm ischemic intestinal segments in 30 additional rats. Again, half were treated with hyperbaric oxygen as previously described for 7 days. There was no difference between the controls and the hyperbaric oxygen group in the rate of perforation (4 of 15 [27%] versus 1 of 15 [7%]) or stricture rate (8 of 15 [53%] versus 9 of 15 [60%]). We concluded that hyperbaric oxygen therapy is of limited value for the treatment of intestinal ischemias.

Laparoscopic pelvic lymphadenectomy has been applied to stage prostate cancer since 1989. These same laparoscopic techniques are being used to stage other urological malignancies. This report will detail the role of laparoscopic lymphadenectomy in staging genitourinary malignancies.

The objective of this study was to determine whether decreased gonadal function is a risk factor for hip fracture in elderly men. The study was a matched case-control study performed at an in-hospital orthopedic service at a semi-rural and academic tertiary care center. The patients were seventeen men who presented with hip fractures after simple falls over a 10-month period, 11 men with a history of hip fractures in the preceding 25 months, and 28 randomly selected age-, race-, and living status-matched control subjects (mean age 73 years). Serum pooled total testosterone (9.2 +/- 5.5 nmol/L vs. 12.8 +/- 5.4 nmol/L; p less than 0.02) and free testosterone (37.9 +/- 18.8 pmol/L vs. 48.4 +/- 20.6 pmol/L; p less than 0.03) were significantly lower in hip fracture vs. control patients. Testosterone deficiency was found in 20 (71%) hip fracture men vs. 9 (32%) of the controls (p = 0.003; odds ratio 5.3). Analysis of testosterone values within the stratum of absence of any chronic disorder revealed similar results. Serum 25-hydroxyvitamin D levels were significantly lower in the hip fracture group than in control men (p less than 0.001). The conclusion is that gonadal deficiency appears to be an important and heretofore understudied risk factor for hip fractures in men. Prevention of hip fractures in men may involve early recognition and treatment of testosterone deficiency.

A woman underwent cesarean delivery for premature labor, breech presentation, and ruptured membranes. Placenta accreta associated with uterine atony and severe hemorrhage was diagnosed. Prostaglandin E1 instead of prostaglandin F2 alpha was inadvertently administered in an effort to control the hemorrhage. The resulting complications included profound hypotension, disseminated intravascular coagulation, and ventricular tachycardia.

We have performed cytogenetic studies on five renal oncocytic neoplasms (three grade 2 tumors and two grade 1 tumors) identified histologically by light microscopy. One grade 1 tumor failed to produce mitotic cells. The other four tumors exhibited both normal and abnormal cell lines. Numerical abnormalities were found in both the single grade 1 and two of the grade 2 tumors whereas structural abnormalities were limited to grade 2 tumors. Aneuploidy of chromosome 12 was observed in both grade 1 and 2 tumors. Grade 2 tumors showed more extensive numerical change than the grade 1 tumors. Abnormalities of chromosome 3 characteristic of renal cell carcinoma were not found in any tumor in this series. A combination of C-banding and HaeIII endonuclease banding was used to identify an ambiguous marker. In our four cases and in the cases previously reported, loss of a sex chromosome, abnormalities of chromosomes 1 and 22, and trisomy 12 are findings most often observed in renal oncocytoma.

Cryptococci react positively with various histochemical stains, including the Fontana-Masson (FM), which stains the cell wall, and mucin stains, such as alcian blue and mucicarmine, which stain the capsule. Combinations of the FM stain with both the alcian blue and mucicarmine stains were performed on paraffin-embedded tissue specimens that were obtained from 15 patients who had culture-proved cryptococcosis. Combined FM-mucicarmine and FM-alcian blue stains were compared with other individual fungal stains. The FM stain, followed by either the mucicarmine or alcian blue stain, distinctively demonstrated both the cell wall and capsule of most organisms. More organisms were recognized in the combined stains than with either stain done individually. No interference between the stains was noted. Combining the FM stain with either of these two mucin stains appears to be helpful for identifying cryptococci.

Some deaths during the first year of life are classified as sudden infant death syndrome (SIDS), the diagnosis of which requires a complete autopsy without adequate explanation for the death. We report a 1-month-old infant whose clinical history was fairly typical for SIDS. Postmortem examination was remarkable in revealing clinically unsuspected central nervous system (CNS) abnormalities, including lobar holoprosencephaly, absence of the olfactory tracts and grooves (arhinencephaly), subependymal gray matter heterotopias, and delayed myelination. Although the CNS findings do not adequately explain the patient's sudden death, this case illustrates the need for a complete autopsy to include careful CNS evaluation, especially in any presumed SIDS death.

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Arachnoid cysts of the spinal canal are relatively common lesions that may be either intra- or extradural. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots. We report a case in which an intradural thoracic arachnoid cyst became symptomatic after a routine decompressive lumbar laminectomy for spinal stenosis. Myelography revealed no abnormality, although magnetic resonance imaging and computed tomography after myelography demonstrated a mass within the posterior aspect of the thoracic spinal canal associated with anterior displacement and compression of the spinal cord. A change in the flow dynamics of the cerebrospinal fluid probably allowed the development of spinal cord compression due to one of the following: expansion of the cyst, decreased cerebrospinal fluid buffer between the cord and the cyst, or epidural venous engorgement. A concomitant and more cephalad lesion such as an arachnoid cyst should be considered when myelopathic complications arise after lumbar surgery. Magnetic resonance imaging and computed tomography after myelography are useful to demonstrate the additional pathological processes.

A series of experiments were conducted to investigate the effect of the monoamine oxidase inhibitor (MAOI), phenelzine, on thiopental anesthesia, electroshock, and blood pressure. After demonstrating that phenelzine (1 mg/kg/day orally) produced the same decrease in pig platelet monoamine oxidase as seen in humans, we compared MAOI-treated vs. non-MAOI-treated groups of pigs following anesthesia and electroconvulsive shock (ECS). In the majority of pigs, the increase in blood pressure associated with general anesthesia and ECS is no greater after MAOI treatment than after no MAOI treatment. One phenelzine-treated pig demonstrated an excessive catecholamine surge and elevated blood pressure.

An 11-year-old black girl presented with a nodule at the tip of the left thumb that eroded the underlying tip of the distal phalanx. The tumor was composed of junctional nests and uniform atypical spindle melanocytes that formed broad fascicles and diffusely permeated the dermis. Scattered collections of Kamino bodies were present. A single enlarged left axillary lymph node was noted 9 months after the initial presentation. The lymph node measured 7 x 4.5 x 2.5. cm and was replaced by metastatic tumor composed of fascicles of spindle melanocytes. Immunohistochemical examination demonstrated immunoreactivity for S100, HMB45, and Leu 7, and ultrastructural examination revealed the presence of premelanosomes in the primary and metastatic tumor. Now, more than 10 years since her initial presentation, the patient is well with no further manifestation of the disease.