Biomedical subjects
Publications and source records attributed to M W Flye.
Eight chronic schizophrenia patients completed a research program consisting of ten weekly sessions of active hemodialysis and ten weekly sessions of sham dialysis in a double-blind design. Previous reports of therapeutic efficacy were not substantiated. None of the patients improved during active dialysis; four patients worsened.
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From November 1977 through June 1979, 26 of 28 nonuremic patients had forearm arteriovenous fistulas successfully created for dialysis, lymphapheresis or vascular access. To improve patency, aspirin and heparin therapy was begun the night before operation and continued postoperatively in all except one patient. No major change in coagulation parameters resulted from this treatment. Twenty-five radial artery to cephalic vein fistulas were created in 23 patients, brachial artery to basilic vein fistulas in 3 patients, and 8 mm polytetrafluoroethylene brachial artery to basilic vein loop grafts in two patients. Early fistula failures (within 11 days) required thrombectomy once in four patients and twice in another patient. A sixth patient was not given heparin or aspirin and required multiple thrombectomies before the graft was removed because of infection. One other patient refused further surgery after two unsuccessful attempts to create an arteriovenous fistula. In the remaining 26 patients, the fistulas have been successfully maintained, and in 18 patients more than 214 dialysis or lymphapheresis treatments have been performed without problems. The successful establishment of arteriovenous fistulas in nonuremic patients has been achieved by giving aspirin and low dose heparin therapy, which appears to be an integral step in maintaining patency.
Twenty consecutive patients with pulmonary infiltrates undiagnosed by routine, noninvasive methods were entered into a prospective study designed to evaluate the diagnostic yield of four methods of lung biopsy. Percutaneous aspiration needle, cutting needle, transbronchial, and open (anterior thoracotomy) biopsy were performed synchronously on all patients. Specimens were evaluated by microbiological, virological, and pathological methods. The diagnostic yields of the four methods were as follows: aspiration needle, 29%; cutting needle, 53%; transbronchial, 59%; and open lung biopsy, 94%. Open lung biopsy was significantly better in yielding a diagnosis than aspiration needle (p less than 0.001), cutting needle (p less than 0.001), and transbronchial biopsy (p less than 0.04).
Twenty-two patients with chylothorax have been treated at the National Institutes of Health since 1955. In 9 of these patients, the condition resulted from an antecedent operation and in 13, it occurred without a history of prior operation (nontraumatic). All 6 of the patients with tumors in whom nontraumatic chylothorax developed had a lymphoma. Four of these 6 also had a chylous ascites, while 6 of the 7 patients without tumors had an associated chylous ascites. Only 3 of the 13 patients with nontraumatic chylothorax responded to nonoperative therapy alone with stabilization of the pleural effusions. A single patient with systemic lupus erythematosus responded to steroid therapy. In contrast, 3 of 4 patients who underwent thoracotomy for nontraumatic chylothorax had permanent relief of their chylous pleural effusions. In the absence of medically treatable disease, thoracotomy with ligation of the thoracic duct and/or pleurectomy or pleurodesis can provide substantial palliation for patients with nontraumatic chylothorax, even when a discrete source of lymph leakage cannot be localized or ascites is present. Early surgical therapy of nontraumatic chylothorax is advocated in such circumstances.
The incidence of parathyroid carcinoma is no more than 0.5 to 3% of parathyroid neoplasms and can often be cured by an adequate initial surgical excision. If the carcinoma has already spread outside the capsule or is implanted at surgery, the chance of local recurrence is high, but is best managed by surgical resection of any recurrence. Distant metastases occur less frequently, but the associated hypercalcemia is poorly controlled by hormonal, chemotherapy, or radiation therapy. Though the chance for cure is small, a review of previously reported cases and our own experience leads us to encourage an aggressive search for metastases, and if possible, surgical resection. If not curative, this approach will often allow prolonged palliation of the effect of hypercalcemia.
Forty-seven patients treated by at least 28 days of thoracic duct drainage (TDD) before cadaveric renal transplant are compared with 63 patients treated with standard immunosuppression. The TDD patients were begun on half the dosage of steroids, and at 30 days were receiving approximately two-thirds the dose that the non-TDD patients received. Acute rejection occurred in 35% of the TDD group, as compared with 61% of the non-TDD group. Graft survival in the TDD patients was twice as good as the non-TDD patients at all time intervals. The patient survival rates were not significantly different between the two groups. TDD pretransplant favorably affects cadaveric renal allograft survival for at least five years.
The survival of renal allografts between SLA-matched swine has been found to be subject to non-SLA-linked Ir gene control. Using three herds of miniature swine, each homozygous for a different SLA haplotype (designated aa, cc, and dd, respectively), we initially observed that all animals of the c haplotype rejected SLA-matched renal allografts. In contrast, the subset of dd animals which were the product of continuous homozygous matings since establishment of the dd herd (ddR) accepted SLA-matched grafts indefinitely without any immunosuppression. A formal backcross study was therefore performed in which offspring of (cd x ddR) matings (designated cdbc and ddbc) were bilaterally nephrectomized and transplanted with SLA-matched renal allografts. Acceptors and rejectors were found among both backcross types, with a total of 6 of 17 (35%) of the animals dying of renal failure secondary to rejection. When ddbc animals were used as donors for ddR recipients, all grafts were accepted, ruling out the possibility that rejection was attributable to strong non-SLA antigens segregating within the cc herd. These results are consistent with a model in which rejection of SLA-matched renal allografts is controlled by either one or two non-SLA-linked immune response genes. These findings raise the possibility that the observed 5 to 15% frequency of rejection of HLA-identical living related donor renal allografts in man could involve similar immune response gene control.
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Noncardiogenic pulmonary edema occurred in an anesthetized patient during an otherwise uneventful laparotomy. Following transfusion of an individual unit of whole blood, routine intraoperative monitoring detected sudden major pulmonary shunting (increased alveolar-arterial oxygen gradient) and an increased physiological alveolar dead space (increased arterial-alveolar carbon dioxide gradient). The noncardiac pulmonary edema probably resulted from the presence of a leukoagglutinin against the patient's granulocytes in the donor's plasma. This antibody had no apparent specificity for known HLA, neutrophil, or blood group antigens. The acute respiratory failure was transient, resolving in 72 hours with respiratory support. The presence of otherwise unexplained noncardiogenic pulmonary edema during or soon after a blood transfusion should suggest the possible diagnosis of a leukoagglutinin reaction.
A 52-year-old female presented with an extensive retroperitoneal sarcoma and intraluminal inferior vena caval extension. Presumably during resection, embolization of a tumor fragment occurred to the right pulmonary hilum. The patient was asymptomatic for 16 months until a right hilar mass developed on a follow-up chest x-ray. Pathological examination of the gross and microscopic sections of the pneumonectomy specimen confirmed the intra-arterial location of the tumor mass. Widespread systemic metastasis became evident soon after pneumonectomy.
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To examine the usefulness of pulmonary function testing in the clinical management of patients with Wegener's granulomatosis, 22 subjects with biopsy proved disease were evaluated using routine functional parameters. Although reduced lung volumes and diffusing capacity occurred frequently, the most common abnormality was in obstruction to airflow. Comparison of these functional parameters with roentgenographic and clinical findings revealed that reduced lung volumes were useful in detecting focal infiltrates, mass or cavitary lesions and diffuse interstitial involvement whereas airflow measurements were useful in detecting focal large airway lesions. In people with evidence of limitation of airflow, respiratory complications frequently developed in the form of acute tracheal obstruction of lobar collapse. In addition, serial evaluation of lung function during treatment revealed that although in most patients lung volumes and airflow obstruction improved or stabilized, a reduction of diffusing capacity was common. These studies suggest that routine pulmonary function testing may be a useful tool in the staging of patients with Wegener's granulomatosis and in following responses to therapy.
To determine whether serum beta 2 microglobulin could be useful as a tumor marker in patients with testicular cancers, sera stored in our serum bank from 23 patients were assayed by radioimmunoassay for beta 2 microglobulin levels. Sera were selected from 12 preorchiectomy patients, 8 patients who had undergone orchiectomy, and 3 patients who had undergone orchiectomy and retroperitoneal lymphadenectomy. Patients with other genitourinary tract disorders and normal age and sex-matched controls were assayed for comparison. The laboratory range for normal serum beta 2 microglobulin values was 1.1 to 2.4 mg/L. Patients without documented testicular tumors had values ranging from 1.4 to 9.7 mg/L. Values for normal controls ranged from 1.7 to 2.4 mg/L. Only 3 patients (12.5 per cent) had elevated serum beta 2 microglobulin values. Serum beta 2 microglobulin seems to have no value as a tumor marker in patients with testicular tumors.
Thirty-one patients undergoing thoracotomy were prospectively randomized to receive (1) no nerve blocks (n = 12), (2) placement of percutaneous catheters for intermittent nerve blocks with bupivacaine (Marcaine) (n = 10), or (3) bupivacaine nerve blocks intraoperatively (n = 8). One patient refused postoperative evaluation and was not included in this study. All patients received similar preoperative, intraoperative, and postoperative medications. Comparison of preoperative and postoperative arterial blood gases, assessments of pain and alertness, and chest roentgenograms showed no statistical advantage for any group. Analgesic requirements and pulmonary functions (functional residual capacity, tidal volume, minute ventilation peak flow, or forced expiratory volume) did not differ among the groups. Statistically significant differences were seen in mean respiratory rate and forced vital capacity. These differences, however, indicate that bupivacaine either by intraoperative use or by intermittent percutaneous administration did not improve postoperative increases in respiratory rate or decreases in forced vital capacity.
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Conventional linear x-ray tomography is often used to search for pulmonary metastases but tends to underestimate extent of disease when compared with operative findings. In a prospective study, operative findings were correlated with computed axial tomography and conventional linear tomography performed on 25 patients with a history of extrathoracic malignancy and pulmonary nodules. Computed tomography detected 69 nodules of which 31 proved to be metastases. Conventional linear tomography detected 38 nodules of which 25 were metastases. Of the 54 resected nodules measuring greater than 3 mm, computed tomography detected 42; whereas conventional tomography detected 32. Only six of the 31 additional nodules (20%) detected by computed tomography and not by conventional tomography proved to be metastases. These results suggest that computed tomography is more sensitive than conventional tomography in detecting small pulmonary nodules; however, there is diminished specificity in identifying metastatic nodules.
Four patients with active, severe rheumatoid arthritis were subjected to the removal of circulating lymphocytes (lymphapheresis) for a 6-week period by use of a continuous flow cell centrifuge. Repetitive venous access was gained through forearm arteriovenous fistulae. In all patients the Ritchie-Camp articular index declined rapidly in the first week and more slowly therafter for a total mean drop of 61% below the initial value. The index continued to decline after lymphapheresis but exacerbation of disease activity developed at an average of 19 weeks. No significant untoward effects of the procedure were observed; occasional transfusions were required to compensate for the small, unavoidable erythrocyte loss.