Biomedical subjects
Publications and source records attributed to D R Cole.
African American elders are a diverse group whose values and beliefs are part of the ethics of United States society. The interplay between these beliefs and the health care system offers many challenges for the geriatrician. Addressing issues of autonomy, beneficence, nonmaleficence, truth-telling, confidentiality, and justice are important in caring for African American elders.
Prolactinomas are the commonest pituitary tumour. They are more frequent in women and account for up to 15% of patients with amenorrhoea (through secondary gonadotrophin suppression). Here we present two patients with previously unrecognized giant prolactinomas, one of whom is probably unique in having radiological evidence of progression from micro to macro prolactinoma in the absence of treatment. Both were being considered for hormone replacement therapy. These tumours are known to be oestrogen sensitive and potentially life threatening. Both had been investigated for amenorrhoea prior to the availability of prolactin assays; no other cause had been found. Amenorrhoeic patients investigated prior to the early 1970s should be reviewed with this in mind. Patients with untreated microprolactinomas should probably be monitored indefinitely.
Tetrahydrobiopterin (BH4) is a pteridine product which is released by rodent macrophages on activation by cytokines. We have used serial pancreatic biopsy, and measurement of serum biopterin at 30, 60, 90 and 120 days in the BB/S rat to relate histological change to macrophage activation during the course of pre-diabetes. Using immunohistochemistry, and an arbitrary scoring system read blind and standardised against day 30, we found that pancreatic MHC class I, MHC class II and infiltrating macrophage staining were up-regulated in the BB/S diabetes-prone rats (n = 17) at day 60, markedly so at day 90, and less so at day 120. Staining for resident pancreatic macrophages remained unchanged throughout in diabetes prone, diabetes resistant and Wistar (n = 28) control animals. Serum biopterin fell progressively and identically with age in BB diabetes resistant rats (n = 11) and Wistar controls. No change in weight gain or biopterin levels was observed in the biopsied animals. Mean serum biopterin levels in diabetes prone rats (of which 13 of 17 became diabetic at median 85 days) were the same as in diabetes resistant and Wistar rats at days 30, 60 and 120, but showed a striking and highly significant elevation (p < 0.001) at day 90. Although macrophages infiltrate the islet early in pre-diabetes, the timing of their activation is unknown. The rise in biopterin we observed is a potentially important immunological event which occurred late in the progression of pre-diabetes. This acute terminal event has not been reported previously, and may modify current concepts concerning the tempo of cell destruction during pre-diabetes.
Microencapsulated islet grafts implanted into the peritoneal cavity of a variety of animal models of diabetes have been shown to reverse hyperglycaemia over prolonged periods without immunosuppression. Here, effects of these grafts on intermediary metabolites, diurnal blood glucose and glycated haemoglobin were studied in streptozotocin-diabetic Wistar rats. Following transplantation (approximately 3000 islets) glucose and the ketone 3-hydroxybutyrate fell significantly (glucose: 19.1 +/- 0.6 (SD) to 9.2 +/- 4.3 mmol/l, p < 0.01; 3-hydroxybutyrate: 1.51 +/- 0.48 to 0.55 +/- 0.38 mmol/l, p < 0.02) and remained within/close to the normal range for at least four weeks. In control diabetic animals, values remained abnormally elevated. There was no difference in lactate, alanine or glycerol between the two groups. In transplanted animals there was a marked variation in blood glucose over a 24h period, values being low during daylight hours but with nocturnal peaks (up to 25 mmol/l) during the animals' normal feeding time. Glycated haemoglobin was also lower in transplanted animals but did not return to normal and the difference was not significant. In conclusion, microencapsulated islet grafts ameliorated the diabetic state. However, normal metabolic homeostasis was not achieved. The intraperitoneal site precludes direct graft vascular access and this may be a contributory factor. Additionally, daytime blood sugar values in murine models of diabetes may be a poor guide to graft function and glucose tolerance.
Alginate-polylysine microencapsulation has been proposed as a method of protecting transplanted pancreatic islets against immunological attack. Using this technique, prolonged graft survival has been reported in some diabetic animals. However, in the spontaneously diabetic insulin-dependent BB/E rat we found that intraperitoneal implantation of microencapsulated islets had only a short-lived effect on hyperglycaemia. Recovered microcapsules (both those implanted empty and containing islets) were surrounded by a foreign body type cellular overgrowth and, although many capsules remained intact, encapsulated islets were observed to be disintegrating. Loss of Beta cells was confirmed by immunohistology. Various polymer materials used in artificial membranes have been shown to activate macrophages involved in foreign body reactions and induce synthesis of interleukin-1 beta, a known Beta-cell toxin. Reduced secretion of insulin and progressive islet damage (indicated by a significant reduction in residual islet insulin and DNA content) were demonstrated when microencapsulated islets were incubated with interleukin-1 beta in vitro for 9 days. Similar effects were seen following exposure to a combination of gamma interferon and alpha tumour necrosis factor. Successful use of microencapsulation in islet transplantation depends upon the development of biocompatible membranes. The exclusion of smaller molecules, such as cytokines, which may be involved in foreign body mediated damage and microencapsulated islet graft rejection, could also be important.
Patients who seek care for foot problems may present to the podiatrist with concurrent problems, such as anxiety, depression, phobias, personality disorders, and psychoses. These may or may not have any direct relationship to the pathogenesis of the foot problem. The podiatrist may learn of the presence of an emotional problem directly from the patient or from a family member. In many cases, the patient may be unaware or deny the presence of an emotional problem, leaving the podiatric physician in the dark about the patient's mental health state or its implications for the management of the skin problem. In a review of the psychosomatic aspects of dermatology, Koblenzer offered a working classification of the psychodermatoses. This is helpful to the podiatrist in recognizing those dermatologic disease states in which the various aspects of the individual participate in the disease, signs and symptoms of the disease, and the potential psychological value of the disease for the patient. It is also helpful to the podiatrist for recognizing those dermatoses in which psychiatric consultation may be useful so that recognition, treatment, improvement, and perhaps cure may be effected quickly.
HIV infection causes a wide spectrum of complications affecting all organ systems. These complications may be primary to the direct infection of a specific organ system by HIV or secondary to the immunodeficiency associated with HIV infection. These complications may be specific to certain stages of HIV infection. Selected common complications of HIV infection include pulmonary, neurologic, GI, dermatologic, oral, ocular, endocrine, and hematologic complications.
Obviously, physicians prefer to use their office hours practicing medicine, therefore, they may tend to overlook these administrative functions. In today's busy practice, finding time to review procedures often is difficult. However, an office error becomes wholly the responsibility of the physician when it leads to a misdiagnosis or failure to diagnose. Periodic review of office procedures may help improve patient care and avoid litigation.
We describe the clinical and pathological features in nine members of a large British family with von Hippel-Lindau disease. Twenty living family members underwent detailed assessment for features of the disease, including retinal examination and computed tomography of the head and abdomen. The hospital records of three deceased family members were reviewed and detailed information about a fourth was obtained from members of the family. As a result of this study, three asymptomatic family members were found to have features of the disease and all three living affected family members were found to have additional features. Lesions discovered included retinal angiomas requiring treatment in four family members, one asymptomatic renal cell carcinoma and one asymptomatic pancreatic endocrine tumour. We also report the occurrence of a spermatic cord mesenchymal hamartoma in von Hippel-Lindau disease.
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Recent studies have shown that students and residents choosing Family Medicine career orientations have attained an academic parity with their counterparts in other specialties which was not demonstrated by their general practitioner predecessors. Similarly, the advent of Family Practice residencies and undergraduate course work has significantly altered the educational experience of today's medical students. This study adds to the literature by comparing a third element, the social character of Family Medicine oriented students, residents and practicing physicians. Three subgroups of Family Medicine oriented individuals; students, residents, and physicians, were surveyed through a mailed questionnaire. A study population of 768 individuals yielded a 73% response rate. The findings show that students and residents share a common pattern of identities and that this pattern is not shared with the physician subgroup. This results in rejection of the cohort replication theory. It also suggests a need for Family Practice training to provide role models from the new and emerging generation of family physicians.
We report success with CT guided percutaneous catheter drainage of deep neck abscesses. The cost efficacy and decreased morbidity of percutaneous catheter drainage has been proved in abdominal and retroperitoneal abscess management, and CT for diagnosis of deep neck infections is well established. The logical application of a proven technique to a new anatomical location has the added potential benefit of improved cosmetic result.
These cases illustrate the potential effectiveness of a fractionated combination chemotherapy program in controlling invasive operable cancer of the bladder without side effects and with sustained normal bladder function. It should be emphasized that these patients had refused any other modality, including surgery, radiation therapy, and standard dosage chemotherapy. At this time all patients are free of clinical disease, living normal lives, and have suffered no side effects from the treatment protocol. The authors believe that by continuous monitoring and close observation, as was illustrated in case No. 2, X-ray therapy and/or surgery can still be utilized effectively if necessary, and if the patient accepts it at the time. This is only a case report study of three patients for a limited period of time. It is not suggested that this should be the treatment of choice in operable cancer of the bladder; however, it opens up a potential for those patients who refuse surgery and/or X-ray therapy and are not willing to accept the side effects of chemotherapy.
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A case of myelofibrosis successfully treated by the use of splenectomy has been reported. The feeling of the authors is that splenectomy should be considered at a much earlier stage of the disease, when the patient is a better risk with a longer survival. We see no valid physiological reasoning for leaving a spleen in, which is valueless to the patient in addition to causing multiple side effects, directly and indirectly from its size and overactivity. This is especially true when attempts to reduce the size have potential hazards, none are completely effective and when the physiological necessity for this reticulo endothelial site seems to be unnecessary. Perhaps it would be of greatest value if all cases of myelofibrosis should be seen at the inception and throughout by the hematological and surgical service together.