RESUMEN
OBJECTIVES: To identify infants with hyperinsulinism caused by defects of the beta-cell adenosine triphosphate-dependent potassium channel complex and to distinguish focal and diffuse forms of hyperinsulinism caused by these mutations. STUDY DESIGN: The acute insulin response to intravenous calcium stimulation (CaAIR) was determined in 9 patients <20 years with diffuse hyperinsulinism caused by defective beta-cell sulfonylurea receptor (SUR1(-/-)), 3 patients with focal congenital hyperinsulinism (6 weeks to 18 months), a 10-year-old with insulinoma, 5 with hyperinsulinism/hyperammonemia syndrome caused by defective glutamate dehydrogenase (6 months to 28 years), 4 SUR1(+/-) heterozygotes with no symptoms, and 9 normal adults. Three infants with congenital focal disease, 1 with diffuse hyperinsulinism, and the child with insulinoma underwent selective pancreatic intra-arterial calcium stimulation with hepatic venous sampling. RESULTS: Children with diffuse SUR1(-/-) disease and infants with congenital focal hyperinsulinism responded to CaAIR, whereas the normal control group, patients with hyperinsulinism/hyperammonemia syndrome, and SUR1(+/-) carriers did not. Selective arterial calcium stimulation of the pancreas with hepatic venous sampling revealed selective, significant step-ups in insulin secretion that correlated anatomically with the location of solitary lesions confirmed surgically in 2 of 3 infants with congenital focal disease and in the child with insulinoma. Selective arterial calcium stimulation of the pancreas with hepatic venous sampling demonstrated markedly elevated baseline insulin levels throughout the pancreas of the infant with diffuse hyperinsulinism. CONCLUSIONS: The intravenous CaAIR is a safe and simple test for identifying infants with diffuse SUR1(-/-) hyperinsulinism or with focal congenital hyperinsulinism. Preoperative selective arterial calcium stimulation of the pancreas with hepatic venous sampling can localize focal lesions causing hyperinsulinism in children. The combination of these calcium stimulation tests may help distinguish focal lesions suitable for cure by local surgical resection.
Asunto(s)
Transportadoras de Casetes de Unión a ATP , Calcio , Hiperinsulinismo/congénito , Hiperinsulinismo/diagnóstico , Canales de Potasio de Rectificación Interna , Canales de Potasio , Receptores de Droga , Compuestos de Sulfonilurea/metabolismo , Adolescente , Adulto , Calcio/sangre , Estudios de Casos y Controles , Niño , Preescolar , Diagnóstico Diferencial , Técnicas de Diagnóstico Endocrino , Femenino , Humanos , Hiperinsulinismo/sangre , Lactante , Inyecciones Intravenosas , Masculino , Canales de Potasio/genética , Receptores de Droga/genética , Receptores de SulfonilureasRESUMEN
PURPOSE: To review the effectiveness of fallopian tube recanalization (FTR) when performed without restriction based on history or tubal condition. MATERIALS AND METHODS: From October 1989 to July 1992 in 37 consecutive women, aged 22-44 years (mean, 35 years), 42 FTRs were performed (five patients each underwent two FTRs). Water-soluble contrast material and selective ostial salpingography and/or microcatheter technique were used exclusively. Eighty tubes were evaluated, since four patients had previously undergone unilateral salpingectomy. Sixty-three tubes (79%) were occluded at the outset of the procedure. RESULTS: Complete recanalization was achieved in 45 of 63 (71%) occlusions. Adhesions were present in 25 of 80 (31%) tubes, salpingitis isthmica nodosa in 12 (15%), and hydrosalpinx in nine (11%). The 42 procedures resulted in 14 (33%) conceptions, nine (64%) of which involved pathologic tubes. Eleven intrauterine pregnancies resulted in five spontaneous first-trimester abortions, five full-term deliveries, and one continuing pregnancy. CONCLUSION: Favorable conception and live birth rates can be achieved with FTR, despite a high prevalence of tubal disease.
Asunto(s)
Cateterismo , Enfermedades de las Trompas Uterinas/terapia , Adulto , Constricción Patológica , Enfermedades de las Trompas Uterinas/complicaciones , Enfermedades de las Trompas Uterinas/diagnóstico , Enfermedades de las Trompas Uterinas/diagnóstico por imagen , Pruebas de Obstrucción de las Trompas Uterinas , Femenino , Humanos , Histerosalpingografía , Infertilidad Femenina/etiología , EmbarazoRESUMEN
OBJECTIVE: To assess the risk behaviors, knowledge, and beliefs regarding human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) among women and their sexual partners who were Mexican-American men who used intravenous drugs. DESIGN: Survey of male methadone users and their female sexual partners. PARTICIPANTS AND SETTING: Mexican-American male clients at a methadone clinic in Los Angeles, Calif, were consecutively recruited for the study. A method similar to partner contact tracing was used to identify female subjects. One hundred subjects, representing 50 male-female pairs of sexual partners, answered identical questionnaires. The responses from females were compared with those from their male partners. RESULTS: Seventy-four percent of the females disclosed that they used intravenous drugs, and 88% knew that their male partners were intravenous drug users. Of subjects who used intravenous drugs, 73% (27/37) of females and 88% (44/50) of males currently injected themselves and shared uncleaned needles. Seventy-six percent of females and 84% of males never used a condom during the previous year, and about 20% of both sexes had more than one sexual partner. Even though most of the females understood how HIV was transmitted and recognized themselves as at risk for AIDS, they continued to share needles unsafely and place themselves at risk for acquiring HIV infection through sex. CONCLUSION: This group of females and their male sexual partners engaged in multiple behaviors that may contribute to the further propagation of HIV infection.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/psicología , Síndrome de Inmunodeficiencia Adquirida/transmisión , Conocimientos, Actitudes y Práctica en Salud , Americanos Mexicanos/psicología , Asunción de Riesgos , Parejas Sexuales , Abuso de Sustancias por Vía Intravenosa/psicología , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Adulto , Estudios Transversales , Femenino , Humanos , Los Angeles/epidemiología , Masculino , Metadona/uso terapéutico , Conducta Sexual , Abuso de Sustancias por Vía Intravenosa/rehabilitaciónRESUMEN
Fifteen patients with large (average, 15-cm), high-grade soft-tissue sarcomas of the extremities received prolonged selective intraarterial infusions of chemotherapeutic agents in an attempt to permit limb-sparing resection of these tumors, which would otherwise have required amputation. There were seven malignant fibrous histiocytomas, four liposarcomas, two fibrosarcomas, one leiomyosarcoma, and one rhabdomyosarcoma; 73% were grade III. Seven patients underwent two catheterizations, for a total of 22 infusions, which averaged 11.3 days each. There were four catheterization-related complications, including catheter occlusion or dislodgement in one patient each and two cases of arterial thromboembolism in patients in whom anticoagulant dose was not adequate. Both of the latter patients required thrombectomy; one developed gangrene, which precluded limb-sparing surgery. Thirteen of the 15 patients underwent limb-sparing resections, and two underwent amputations. No wound complications occurred. With a median follow-up of 36 months (mean, 34 months), life-table analysis indicates overall and disease-free survivals of 72% and 59%, respectively, at 2 years and 64% and 59% at 3 years. In comparison to other reported therapies, this technique permits limb salvage in most patients without the high wound complication rate associated with preoperative radiation therapy, with equivalent local disease control and survival.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Extremidades , Sarcoma/terapia , Neoplasias de los Tejidos Blandos/terapia , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Cisplatino/administración & dosificación , Terapia Combinada , Doxorrubicina/administración & dosificación , Femenino , Fibrosarcoma/tratamiento farmacológico , Fibrosarcoma/epidemiología , Fibrosarcoma/cirugía , Floxuridina/administración & dosificación , Histiocitoma Fibroso Benigno/tratamiento farmacológico , Histiocitoma Fibroso Benigno/epidemiología , Histiocitoma Fibroso Benigno/cirugía , Humanos , Infusiones Intraarteriales , Leiomiosarcoma/tratamiento farmacológico , Leiomiosarcoma/epidemiología , Leiomiosarcoma/cirugía , Liposarcoma/tratamiento farmacológico , Liposarcoma/epidemiología , Liposarcoma/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Rabdomiosarcoma/tratamiento farmacológico , Rabdomiosarcoma/epidemiología , Rabdomiosarcoma/cirugía , Sarcoma/tratamiento farmacológico , Sarcoma/cirugía , Neoplasias de los Tejidos Blandos/tratamiento farmacológico , Neoplasias de los Tejidos Blandos/cirugía , Tasa de SupervivenciaRESUMEN
The safety and efficacy of the Palmaz balloon-expandable vascular stent and its effect on the results of percutaneous transluminal angioplasty (PTA) were assessed in a prospective study. Technical success was achieved in the placement of 34 of 35 stents (97%) in 27 common and external iliac artery lesions in 19 patients (23 limbs) who presented with disabling claudication, rest pain, or gangrene. Stent placement improved the angiographic results achieved by PTA alone in all 19 patients. Seventeen of 23 limbs (74%) had significant (greater than 20%) elevation of the ankle-arm index after combined angioplasty and stent placement, including nine limbs with occlusive outflow lesions. All 10 patients with continuous runoff distal to the stent and one patient with discontinuous runoff had resolution of their symptoms, remaining unchanged at a mean follow-up time of 6 months. There were three complications: One significantly altered the patient's hospital course, but none detracted from the achieved stent result. Stent placement is effective and does not significantly increase the complication rate of conventional iliac PTA. The current delivery system, however, may limit its utility.
Asunto(s)
Angioplastia de Balón , Arteria Ilíaca , Claudicación Intermitente/terapia , Stents , Ensayos Clínicos como Asunto , Constricción Patológica/terapia , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Factores de TiempoAsunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Infarto del Miocardio/complicaciones , Arritmias Cardíacas/tratamiento farmacológico , Complejos Cardíacos Prematuros/tratamiento farmacológico , Ventrículos Cardíacos , Humanos , Infarto del Miocardio/tratamiento farmacológico , Volumen Sistólico/efectos de los fármacosRESUMEN
To search for electrocardiographic clues of infarction of the right ventricle, we recorded the right-thoracic unipolar leads from V3R to V6R and the following abdominal leads: MD, ME and MI, in a group of 40 normals (control group) and in a group of 40 patients with their first acute transmural myocardial infarction (25 posterior-inferior, 15 anterior wall). We described the predominant ECG morphologies in the control waves (more than 0.04 sec. duration) could be registered in the right anterior thoracic wall in healthy subjects. Based on the findings from our control group and those reported from other investigators, we concluded that to suspect right ventricular involvement in the above mentioned leads, it is required to find necrosis and subepicardial injury waves in at least two of those leads. The most frequently affected leads were V4R and MD. This electrocardiographic "positive" pattern to suspect involvement of the right ventricle was found in 32% of the posterior-inferior left ventricular infarctions. In none of the left ventricular anterior wall infarctions we observed right-sided involvement. The clinical-electrocardiographic correlation was statistically significant. Due to the hemodynamic and therapeutic consequences when right ventricular involvement is suspected, it is convenient to record, in every patient with posterior-inferior myocardial infarction, the special leads described above, more so since the ECG is a simple fast, low cost invaluable auxilliary in the evaluation of the extension of necrosis in the right ventricle.
Asunto(s)
Electrocardiografía , Infarto del Miocardio/diagnóstico , Enfermedad Aguda , Adulto , Anciano , Femenino , Ventrículos Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Miocardio/patología , NecrosisRESUMEN
A group of 19 patients with acute respiratory failure (ARF) of diverse etiology received as a part of their treatment positive and expiratory pressure (PEEP). All of them were evaluated clinically and with several respiratory parameters. The response to treatment, complications and mortality rates are analyzed. The addition of PEEP in the management of this patients was accompanied by a significant increase of the PAO2 (p < 0.001) and a simultaneous decrease in the following parameters: FiO2/PaO2 index, Alveolo-arterial oxygen gradient (A-aDO2) and the pulmonary shunt (Qs/Qt). No hemodynamic deterioration was observed. None of the clinical parameters such as: blood pressure, heart rate and diuresis was significantly modified; neither a significant change in the arterious-venous oxygen gradient (a-vDO2) was detected. Pneumothorax as a complication of the use of PEEP was present in the 10.4% of the patients. The course of the ARF was toward the improvement in most of them at the end of the evolution. The high mortality rate in this study was considered to be secondary to uncontrollable sepsis and also to the presence of multiple organ failure. In none of the cases the poor outcome was secondary to refractory acute hypoxemia. PEEP which is one of the varieties of continuous positive pressure ventilation (CPPV) represents one of the most importants therapeutic advances in the last decade in the management of patients with acute respiratory failure.
Asunto(s)
Respiración con Presión Positiva , Insuficiencia Respiratoria/terapia , Enfermedad Aguda , Adolescente , Adulto , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/diagnósticoRESUMEN
There is little information in the medical literature about the renewal of sexual activity in patients who have suffered an MI. The knowledge which the internist and the cardiologist have are normally insufficient. The equivalents in energetic cost of a sexual relation of a middle aged adult, are similar to those of: a) a simple Master test of two stairs, b) walking rapidly the length of a street, c) climbing two flights of stairs. d) a test with ergometer to 100 watts or 600 kg-m-m, e) to walk the endles band at 3.5 miles/hour, f) to carry out activities equivalent to 6 cal/min. The average of the maximum cardiac frequency which is reached during coitus is from 115 to 120, equivalent to approximately 4-5 mets., during 20-36 seconds. In the post and preorgasmic period (1 min, before and after) the energetic cost is close to 4 mts. It should be emphasized that there should not exist an exact limit after which the patient who has had an MI is permitted to have sexual relations. The sexual activity should be advised if the patient has satisfactorily passed any of the equivalent tests mentioned above. The cardiologist should know these facts and not wait until the patient asks about them; he should have the initiative to openly discuss them with the patient and his partner from the period interhospitalary convalescence of the MI.
Asunto(s)
Convalecencia , Infarto del Miocardio , Adulto , Coito , Femenino , Humanos , Masculino , Relaciones Médico-Paciente , Abstinencia SexualRESUMEN
The effect of verapamil were studied on 50 episodes of supraventricular and ventricular tachycardia in 44 patients. An i.v. dose of 0.10 to 0.15 mg/kg. was used. In 5 cases His bundle electrograms were obtained while maximal dp/dt was determined in 7 others. Sinus rhythm was obtained in 21 (81%) of 26 cases of PSVT. In all cases of rapid atrial fibrillation (n-11), an important decrease in the ventricular response was elicited. Of 7 cases of atrial flutter, verapamil induced sinus rhythm in 3 and a significant decrease in the ventricular rate in 3 others. In 2 out of 6 cases ventricular tachycardia reverted to sinus rhythm. The latency time between the injection and the manifestation of the effect ranged from 2 to 4 minutes. A slight and short-lasting depression of dp/dt was observed in all cases studied. Verapamil produced an increase in the A-H interval in 4 of the 5 cases studied with His bundle recordings. Verapamil was found to be a useful drug to suppress PSVT, to decrease the ventricular response in flutter or atrial fibrillation and to convert some ventricular tachycardias to sinus rhythm. Verapamil should be used with caution in previously digitalized patients and is contraindicated when there is S-A node dysfunction as in the tachycardia-bradycardia syndrome.