Responses to 'bending the rules to get a medication'.
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California↗
Biomedical subjects
M B Stevens
Publications and source records attributed to M B Stevens.
TCA-based blue peel: a standardized procedure with depth control.
BACKGROUND: Trichloroacetic acid (TCA) peels are popular, well known, and widely utilized to correct a variety of skin problems. Different methods exist, ranging from the use of plain TCA to augmented or modified TCA at concentrations ranging from 30% to 50%. However, peel results vary depending upon the physician skill level, patient selection, and patient management. OBJECTIVES: The purpose of this article is to fill the gap for a peel that is deeper than superficial exfoliative procedures yet lighter than a medium-depth peel, to simplify and standardize the TCA peel, to define depth properly based on intraoperative clinical signs, to implement a color guide that facilitates even application of TCA and avoids skip areas, and to identify and minimize variables that may contribute to inconsistent outcomes. METHODS: A coating system for TCA application is created by selecting a specific TCA concentration (15% or 20%), TCA volume (4 or 6 ml, respectively), and a standardized body surface area to be peeled (5%), taking into consideration skin thickness and fragility. Multiple coats of TCA are applied to reach the desired endpoints: papillary dermis (light Blue Peel) or the immediate upper reticular dermis (light/medium Blue Peel). Clinical signs guide the depth achieved (frost quality, even blue, pink sign, epidermal sliding) and correlate retrospectively with healing time (7-10 days). RESULTS: The TCA Blue Peel was found to be a simple and consistent treatment approach for problems related to the epidermis, papillary dermis, and immediate upper reticular dermis. An unexpected benefit was the appearance of skin tightening and a reduction of skin laxity in many cases. This suggests that the papillary dermis and the immediate upper reticular dermis play a significant role in skin tightness. CONCLUSION: A simple coating system for achieving depth-controlled TCA peels is presented with correlation to intraoperative clinical signs. This method makes it easier to peel skin of all racial backgrounds, including nonfacial skin. This is especially useful for many patients previously excluded from having procedures that penetrate beneath the papillary dermis. Commonly encountered variables in chemical peels are presented which may affect outcome.
Chemexfoliation↗
A zinc finger protein that represses transcription of the human MHC class II gene, DPA.
The proximal promoters of all MHC class II genes contain a sequence element, the 19-bp X box, that is conserved in both sequence and position. Extensive analysis using a wide variety of approaches has demonstrated that the integrity of the X box is essential for transcription initiation from all class II genes studied. However, the X box is now recognized to contain two subregions, termed X1 and X2. Radiolabeled oligonucleotides corresponding to the X2 box of the MHC class II genes DPA and DQB were used to screen B cell and T cell expression libraries. A novel cDNA, termed XBR (X box repressor), encoding a putative zinc finger protein that binds specifically to the DPA X2 box was isolated from a human T cell line. The XBR gene encodes a 7-kb message that is ubiquitously transcribed, although at higher levels in tissues of the lymphocytic compartment. Southern blots indicate that this gene is single copy in primates and contains regions that are highly divergent in other species. Overexpression of XBR in a B cell line resulted in a dramatic reduction of transcription from a reporter gene construct driven by the DPA promoter, but not from similar constructs with mutations in the X2 box. Similarly, overexpression of XBR reduced induction of reporter gene activity driven from the DPA promoter in HeLa cells treated with IFN-gamma. XBR may, therefore, mediate transcriptional repression, thus preventing inappropriate MHC class II expression. XBR function may in part explain the dominant trans-acting repression of MHC class II expression reported in cell fusion experiments.
Amino Acid Sequence↗
One hundred anti-Ro (SS-A) antibody positive patients: a 10-year follow-up.
To explore further the varied clinical expression of anti-Ro(SS-A) antibody positive patients and to determine the outcomes of these patients, we followed 100 anti-Ro(SS-A) antibody positive patients, originally seen at the Johns Hopkins Medical Institutions in 1982 and 1983, over a 10-year period. The results of this study indicate that anti-Ro(SS-A) antibody positive patients have a diverse clinical presentation and that the anti-Ro(SS-A) antibody response generally persists for years. Some of these patients appear to have a static disease process for years. However, 65% (51, including 13 deaths, of 78 patients) of the patients for whom we had follow-up data had a chronic (10 years or greater) progressive disease process. Black patients, in general, have an earlier onset of disease and may have a more severe disease than white patients. At least 25% of our anti-Ro(SS-A) antibody positive patients demonstrated a dynamic change in clinical presentation with the development of Sjögren syndrome and/or a progressive "rheumatoid-like" arthritis. Interstitial pulmonary disease, central nervous system disease, and vasculitic insults occur frequently in these patients. Renal disease occurred in 19 anti-Ro(SS-A) positive patients, and in 47% of these renal disease patients, no anti-DNA antibodies (dsDNA or ssDNA) were detected. Cutaneous manifestations are prominent in anti-Ro(SS-A) antibody positive patients with lupus. Photosensitivity and a malar dermatitis were the most common features. Twenty percent of lupus patients had discoid lesions, and 20% had SCLE lesions. Based on this study, we believe that anti-Ro(SS-A) antibody positive patients should be routinely evaluated for the emergence of systemic features. Since these systemic features are at least in part, if not solely, the result of inflammation, early treatment with steroids and/or immunosuppressive agents may minimize the damage and influence in a positive manner the significant morbidity and mortality observed in some anti-Ro(SS-A) antibody positive patients.
Adolescent↗
Fetal lamb pulmonary hypoplasia: pulmonary vascular and myocardial abnormalities.
Neonatal pulmonary hypoplasia resulting from a congenital diaphragmatic hernia (CDH) produces hemodynamic changes and morphologic abnormalities of the pulmonary vasculature. To characterize the myocardial and pulmonary vascular status of the fetus with pulmonary hypoplasia, we studied four chronically instrumented, near-term fetal lambs with pulmonary hypoplasia, induced by producing a diaphragmatic hernia. We found an elevation in the pulmonary arterial pressure (control, 43.8 +/- 5.9 mmHg; CDH, 58.8 +/- 9.1 mmHg; p < 0.05), an elevation in the systemic arterial pressure (control, 43.8 +/- 0.48 mmHg; CDH, 58.6 +/- 6.7 mmHg; p < 0.05), and an elevation in the pulmonary vascular resistance (control, 0.47 +/- 0.11; CDH, 3.87 +/- 1.9; p < 0.05). In addition, though the total pulmonary blood flow was reduced (control, 83.5 +/- 32.9 mL/min; CDH, 22.2 +/- 17.6 mL/min; p < 0.05), the blood flow reduction was proportional to the reduction in the lung mass (control, 79.8 +/- 28.1 [in flow per 100-g lung weight]; CDH, 85.4 +/- 71.7). The increase in the pulmonary vascular resistance in relation to the unit lung mass (control, 0.55 +/- 0.33; CDH, 0.99 +/- 0.5) was not as pronounced as its increase in relation to the total pulmonary blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)
Abnormalities, Multiple↗
Tension-type headaches.
Tension-type headaches are generally characterized by slowly progressive, dull, constant, nonpulsatile pain in the occipital and posterior neck or in a "headband" distribution. Episodic tension-type headaches occur fewer than 15 times a month, and chronic tension-type headaches occur more than 15 times a month for at least six months. Cranial radiography, computed tomographic scanning, electroencephalography and other adjunctive tests are unnecessary if the presentation is typical and the headache is not associated with seizure activity, mental status changes, neurologic deficits and other markers of potentially serious underlying disease. Treatment of episodic tension-type headaches may include topical heat or cold packs, exercise and other stress-reduction techniques, mild analgesics, muscle relaxants and trigger-point injections. Some patients may benefit from antidepressants and individual or family counseling.
Diagnosis, Differential↗
The clinical spectrum of SLE.
Systemic lupus erythematosus is a complex immunologic disorder with an equally complex clinical presentation and course. In recent years, the earlier recognition of milder disease supported by immunologic markers coupled with means of intervention and suppression, as well as medical/surgical advances has resulted in increases in quality of life and survival.
Humans↗
The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis.
Criteria for the classification of giant cell (temporal) arteritis were developed by comparing 214 patients who had this disease with 593 patients with other forms of vasculitis. For the traditional format classification, 5 criteria were selected: age greater than or equal to 50 years at disease onset, new onset of localized headache, temporal artery tenderness or decreased temporal artery pulse, elevated erythrocyte sedimentation rate (Westergren) greater than or equal to 50 mm/hour, and biopsy sample including an artery, showing necrotizing arteritis, characterized by a predominance of mononuclear cell infiltrates or a granulomatous process with multinucleated giant cells. The presence of 3 or more of these 5 criteria was associated with a sensitivity of 93.5% and a specificity of 91.2%. A classification tree was also constructed using 6 criteria. These criteria were the same as for the traditional format, except that elevated erythrocyte sedimentation rate was excluded, and 2 other variables were included: scalp tenderness and claudication of the jaw or tongue or on deglutition. The classification tree was associated with a sensitivity of 95.3% and specificity of 90.7%.
Aged↗
Catabolic effects of high-dose corticosteroids persist despite therapeutic benefit in rheumatoid arthritis.
Although corticosteroids (CS) cause nitrogen wasting in healthy humans, it is not known whether the salutary antiinflammatory and appetite-stimulating effects of CS in inflammatory diseases mitigate this effect. We measured nitrogen balance before, during, and after 3 d of high-dose methylprednisolone therapy in nine patients with flare-ups of rheumatoid arthritis. There was evidence of preexisting somatic protein and fat depletion in seven of nine subjects. Patients were allowed to eat freely on a metabolic ward. Nitrogen balances were -0.89 +/- 1.38 g/d (means +/- SEM) before CS therapy, -5.77 +/- 1.30 g/d during therapy (P less than 0.001), and -3.54 +/- 1.38 g/d after therapy (P less than 0.01) despite increased energy and nitrogen intake and clinical resolution of inflammation during and after the pulse therapy. We conclude that patients with rheumatoid arthritis are often cachectic and high-dose CS cause nitrogen wasting in these patients despite an antiinflammatory and appetite-stimulatory benefit.
Adrenal Cortex Hormones↗
Intravenous pulsed steroids in rheumatoid arthritis: a comparative dose study.
This prospective, double blind study was undertaken to test the efficacy of intravenous "minipulse" (100 mg) methylprednisolone (MP) therapy versus standard pulse (1000 mg) MP therapy in rheumatoid arthritis (RA). Thirty-six patients with RA synovitis flares were randomized to receive either 100 or 1000 mg MP IV QD x 3 doses. These 2 universally comparable groups exhibited no statistically significant differences in their striking prompt and sustained clinical improvement. These data suggest that minipulse MP is as efficacious as conventional pulse MP in the treatment of RA flares.
Adult↗
Usefulness and limitations of regional cardiac sympathectomy by phenol.
We evaluated the completeness and extent of regional sympathetic denervation of the left ventricle after epicardial painting with phenol in anesthetized dogs. In a region encircled by phenol, the effect of electrical stimulation of efferent sympathetic fibers on myocardial contractility and coronary vascular resistance was completely abolished within 30 min. Denervation extended to untreated regions innervated by sympathetic fibers crossing the phenol line. For at least 4 h after phenol application, intravenous infusion of isoproterenol or coronary arterial infusion of tyramine increased myocardial contractility in the denervated region; norepinephrine content and neurotransmitter uptake were normal, indicating that nerve terminals, postjunctional receptors, and myocardium remained functional. However, after 3-14 days, tissue catecholamine content and transmitter uptake in the encircled area were markedly reduced. The results suggest that careful evaluation is necessary in selecting a fully innervated control region in studies employing regional sympathetic denervation with phenol.
Administration, Topical↗
Effects of acute ischemia in the dog on myocardial blood flow, beta receptors, and adenylate cyclase activity with and without chronic beta blockade.
We ligated the left anterior descending coronary artery for 1 or 2 h in 31 purebred beagles. We did not detect any changes in beta-adrenergic receptor density or affinity when normal and ischemic zones were compared, either in the subendocardium or in the subepicardium. In the ischemic zones, there was a significant decline in all measures of adenylate cyclase activity, including activity mediated by the beta-adrenergic receptor. By contrast, after chronic beta-adrenergic blockade (1.5 mg/kg propranolol i.v. twice daily for 7 d), there was an increase in adenylate cyclase activity stimulated by (-)-isoproterenol relative to adenylate cyclase activity stimulated by guanyl-5'imidodiphosphate (GppNHp) in both normal and ischemic tissue, suggesting that one effect of chronic beta blockade may be to enhance coupling between the stimulatory guanine nucleotide regulatory protein (Gs) and the beta-adrenergic receptor, despite a reduction in the number or function of Gs units. Chronic beta blockade also led to up regulation of beta-adrenergic receptor density in subepicardial regions. After 20 min of reperfusion following 2 h of ischemia, adenylate cyclase activity tended to return to control levels, particularly in the subepicardium, where (-)-isoproterenol-stimulated adenylate cyclase activity was not different from normal myocardium. We conclude that chronic beta-adrenergic blockade may have beneficial effects during prolonged episodes of myocardial ischemia by preserving signal transduction mediated by the beta-adrenergic receptor.
Adenylyl Cyclases↗
The effect of verapamil on cerebral cortical and spinal cord blood flow during proximal descending thoracic aortic occlusion.
UNLABELLED: The mechanism of central nervous system (CNS) protection during proximal descending thoracic aortic cross-clamping (PDTAC) for aortic surgery using calcium channel blocking agents is not known. In order to determine the effect of verapamil on CNS blood flow during PDTAC, we calculated cerebral cortical (CC), proximal spinal cord (PSC), and distal spinal cord (DSC) blood flow using the microsphere method in Grade I beagles. Flow calculations were obtained at baseline (pre-PDTAC), following mobilization of the proximal descending aorta for 5-8 cm by ligating 3-5 pairs of intercostal arteries (ICA), during PDTAC (45 min), and during maximal reperfusion. Two groups were studied: 1) control (Cont) untreated (n = 5); 2) verapamil (Ver) treated (0.4 mg/kg IV just before PDTAC and just before reperfusion) (n = 5). CONCLUSIONS: I) Proximal ICA ligation produces no compromise to SC blood flow. II) Verapamil may protect the CNS by: 1) maintaining cerebral autoregulation during reperfusion; and 2) dampening hyperperfusion of the distal SC during reperfusion.
Animals↗
State screening for metabolic disorders in newborns.
Most states have mandatory screening programs for congenital and inherited disorders of metabolism. Physicians may be unaware of their state's requirements, and compiled lists of testing requirements are generally unavailable or incomplete. All states test for congenital hypothyroidism and phenylketonuria. Some states require that newborns be tested for up to six other specific congenital and inherited disorders of metabolism. Some states base their decision to test on demographic data, but there is no uniformity in the tests.
Adrenal Hyperplasia, Congenital↗
The reactive arthritis of giardiasis. A case report.
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Adolescent↗