St. Vincent Charity Hospital

Serums of patients with hereditary angioneurotic edema lack inhibitory activity against the esterase derived from the first component of complement. In one group of patients this lack appears to result from failure to synthesize the esterase inhibitor of the first component of complement, whereas in another group of patients an abnormal, nonfunctional protein is synthesized.

A new segmental spine plate fixation system, utilizing a posterior approach and screw fixation, has been developed for disorders of the lower thoracic or lumbar spine. The indications are significant instability and severe pain relieved by immobilization. This new system uses multiple segmental fixation points through the pedicle "force nucleus" of the vertebral body. The spine plates can be contoured for anatomic positioning, reduction, and rigid stabilization to enhance graft consolidation and fusion. The surgical fixation technique is demonstrated in five case presentations illustrating the application and versatility of the method.

The results of a morphometric study of selected human vertebrae undertaken to provide data for implant design are presented in this report. Twenty-seven dimensions were measured from thoracic (T2, T7, T12) and lumbar (L1-L5) vertebrae using prepared spinal columns from 30 skeletons belonging to the Hamann-Todd Osteological Collection. Maximum and minimum pedicle dimensions indicated that the pedicles are less symmetric cephalad than they are caudal. Vertebral body height increases caudally except posteriorly where, after an initial increase, it decreases in the lower lumbar region. Major and minor body diameters and the major spinal canal diameter slightly increase caudally, whereas minor spinal canal diameter exhibits little or no change.

Posterior lumbar interbody fusion (PLIF) is accepted by many authors as the surgical treatment for herniated discs, degenerative disc conditions, and Grades I and II spondylolistheses. PLIF is now used in conjunction with newly developed segmental spine plates by using transpedicular screw fixation to enhance the osteosynthesis and success rate of interbody fusion. To date, 104 fusions have been performed in 67 patients with no dislocations of any interbody grafts and no indication of absorption, pseudoarthrosis, or infections.

The tendency to have severe attacks of localized alngioneurotic edema may be inherited as an au- tosomal dominant trait (1-7). The hereditary form of angioneurotic edema is also distinguishable by a biochemical abnormality in that affected per- sons lack detectable serum inhibitor of an enzyme derived from the first component of complement (C'1-esterase) (8). This serum deficiency is detectable before the onset of symptoms, which may appear at any time from 1 year of age to adult life. Although serum inhibitor of C'1- esterase is constantly absent from sera of patients, attacks of edema are episodic and self-limited and affect only circumscribed areas of the body. The present studies were undertaken to define changes in C'1-esterase and the components of complement in serum of patients during attacks of edema and during asymptomatic intervals.

Temperature was diminished in a stepwise fashion in the isolated kidney of the dog perfused from a peripheral artery of the original, normothermic animal. Decreased temperature resulted in an appreciable reduction of renal blood flow at constant arterial blood pressure. Increased blood viscosity and vasoconstriction were both responsible for this reduction of flow. Hypothermia also resulted in a reduction in arteriovenous oxygen difference which was roughly proportional to the centigrade temperature. Furthermore, hypothermia exerted a marked but reversible depression of the rate of oxidative metabolism. This effect was relatively more severe than the changes for the body as a whole at equivalent temperatures reported by other investigators.

In three different types of canine heart preparations, it was demonstrated that efferent vagal stimulation exerts a potent, negative inotropic influence upon the ventricular myocardium. In the paced, isovolumetric, left ventricle preparation, vagal stimulation evoked a reduction of left ventricular systolic pressure which, within limits, varied directly with the magnitude of the stimulus. Supramaximal stimulation elicited a mean reduction of 23% in the peak pressure generated by the left ventricle. No differences could be detected between the effects of the right and left vagi upon ventricular contractility. The percentage changes induced by vagal stimulation upon ventricular contractility in the paced heart were less than the percentage changes in heart rate induced in the spontaneously beating heart. In a pumping heart preparation in which a constant rate of venous return was delivered to the left atrium, vagal stimulation consistently elicited an appreciable elevation of left ventricular end diastolic pressure. Another pumping heart preparation was employed in which changes in atrial transport function and mitral valve closure were excluded by the expedient of introducing a balloon into the left ventricle through an apical incision. This balloon was connected to an artificial external circuit with fixed venous reservoir height and peripheral resistance. Vagal stimulation consistently diminished stroke volume, "arterial" pressure, and stroke work in such a circuit.

The effectiveness and safety of warfarin were compared with those of a low-molecular-weight heparin (dalteparin) for the prevention of deep-vein thrombosis after total hip arthroplasty in a prospective, randomized, multi-institutional trial. Patients who were older than eighteen years of age and were scheduled to have an elective primary or revision total hip arthroplasty were eligible; 580 patients were randomized, 550 had the operation and received prophylaxis, and 382 had evaluable venograms. Prophylaxis was provided either with warfarin beginning the night before the operation or with dalteparin beginning two hours before the operation and was continued until venography was performed. Bleeding was assessed on the basis of intraoperative blood loss, transfusion requirements, a decrease in hematocrit, and clinically identified bleeding complications. The prevalence of deep-vein thrombosis was found to be significantly lower in the patients who had received dalteparin than in those who had received warfarin (twenty-eight [15 per cent] of 192 patients compared with forty-nine [26 per cent] of 190 patients; p = 0.006). Deep-vein thrombosis occurred in the calf veins of twenty-one patients (11 per cent) who had received dalteparin and of forty-three patients (23 per cent) who had received warfarin; this difference was significant (p = 0.003). Proximal deep-vein thrombosis occurred in ten patients (5 per cent) who had received dalteparin and in sixteen patients (8 per cent) who had received warfarin; however, with the numbers available, no significant difference could be detected (p = 0.185). We also could not detect a significant difference with regard to the intraoperative and postoperative blood loss, the decrease in hematocrit, and the prevalence of major bleeding complications between the two groups; however, the patients who had received dalteparin had a significantly higher prevalence of bleeding complications involving the operative site (p = 0.03), and a significantly greater percentage required postoperative transfusions (p = 0.001). We concluded that preoperative prophylaxis with dalteparin is significantly more effective than that with warfarin in preventing deep-vein thrombosis after total hip arthroplasty. The greater effectiveness of dalteparin must be considered, however, in light of an increased need for postoperative transfusions and an increase in the prevalence of wound-related bleeding complications.

Abstract Background and Aim Proton pump inhibitors ( PPI ) and H 2 ‐receptor antagonists (H2RA) are frequently prescribed in hospitalized patients with cirrhosis. There are conflicting reports regarding the role of acid‐suppressive therapy in predisposing hospitalized patients with cirrhosis to spontaneous bacterial peritonitis ( SBP ). The aim of this meta‐analysis was to evaluate the association between acid‐suppressive therapy and the risk of SBP in hospitalized patients with cirrhosis. Methods We searched MEDLINE and four other databases for subject headings and text words related to SBP and acid‐suppressive therapy. All observational studies that investigated the risk of SBP associated with PPI / H2RA therapy and utilized SBP as an endpoint were considered eligible. Data from the identified studies were combined by means of a random‐effects model and odds ratios ( OR s) were calculated. Results Eight studies ( n = 3815 patients) met inclusion criteria. The risk of hospitalized cirrhotic patients developing SBP increased when using acid‐suppressive therapy. The risk was greater with PPI therapy ( n = 3815; OR 3.15, 95% confidence interval 2.09–4.74) as compared to those on H2RA therapy ( n = 562; OR 1.71, 95% confidence interval 0.97–3.01). Conclusions Pharmacologic acid suppression was associated with a greater risk of SBP in hospitalized patients with cirrhosis. Cirrhotic patients receiving a PPI have approximately three times the risk of developing SBP compared with those not receiving this medication. Prospective studies may help clarify this relationship and shed light on the mechanism(s) by which acid‐suppressive therapy increases the risk of SBP in hospitalized patients with cirrhosis.

The generation of C'1 esterase activity in siliconed plasma obtained from individuals with hereditary angioneurotic edema in remission tends to occur spontaneously, but can be hastened during its incubation with preparations of activated Hageman factor. This effect of activated Hageman factor could not be shown during its incubation with normal siliconed plasma, nor could consumption of normal serum inhibition of C'1 esterase be clearly shown. Soy bean trypsin inhibitor and heparin could impair this enhanced generation of C'1 esterase but neither inhibits the esterolytic function of C'1 esterase once formed. Trasylol was less effective in blocking this effect of activated Hageman factor. While the mechanism of the effect of activated Hageman factor upon C'1 activation remains obscure, it is apparent that some intermediate steps, possibly involving a kinin-forming system of plasma, may play a role.

Plasma from persons with hereditary angioneurotic edema readily developed the capacity to increase vascular permeability and to induce the isolated rat uterus to contract. Both activities resided in a small, heat-stable molecule that was apparently a polypeptide. Crude preparations of the polypeptide were inactivated during incubation with trypsin. They also failed to produce pain and erythema, but caused markedly increased vascular permeability in human skin. These characteristics differ from those of bradykinin, from which crude preparations of the polypeptide could also be distinguished by electrophoretic mobility and paper chromatographic behavior. Proof that the polypeptide is truly different from bradykinin must await its further purification. Histamine played no role in the activities observed. Although the enzymes functioning to release the permeability factor and kinin activities in hereditary angioneurotic edema plasma were not clearly defined, one or more plasma enzymes other than C'1 esterase presumably participated either in conjunction with C'1 esterase or in pari passu events to release the polypeptide mediating these activities.

Hypoxia causes a cascade of activity from the level of the individual down to the regulation and function of the cell nucleus. Prolonged periods of low oxygen tension are a core feature of several disease states. Advances in the study of molecular biology have begun to bridge the gap between the cellular response to hypoxia and physiology. Hyperbaric oxygen therapy is a treatment for hypoxic- and inflammatory-driven conditions, in which patients are treated with 100% oxygen at pressures greater than atmospheric pressure. This review discusses hypoxia, the physiologic changes associated with hypoxia, the responses that occur in the cells during hypoxic conditions, and the role that hyperbaric oxygen therapy can play as part of the treatment for many patients suffering from diseases with underlying hypoxia.

Progressive subluxation/dislocation of the lesser toes resulting from idiopathic inflammation about one or more of the lesser metatarsophalangeal joints is a common cause of metatarsalgia that is frequently unrecognized or misdiagnosed. The disorder results from a failure of the plantar plate and collateral ligaments that stabilize the metatarsophalangeal joints and is typically associated with abnormal forefoot loading patterns. The authors refer to this condition as predislocation syndrome and have devised a clinical staging system that is based on the clinical signs and symptoms present during examination. A thorough review of predislocation syndrome and an overview of the conservative and surgical treatment options available for this disorder are presented.

Bilateral cervical vagotomy resulted in a threefold increase in the blood titer of antidiuretic hormone (ADH) in the dog. Occlusion of both common carotid arteries in dogs with vagi intact was without effect. However, after vagotomy, occlusion of the common carotid arteries resulted in an additional 2.5-fold increase in the blood level of ADH. This response was blocked by denervation of the carotid sinuses 1–2 weeks prior to the experiment. Baroceptors located at the junction of the thyroid and common carotid arteries do not appear to be of great importance in this response, since occlusion above the thyrocarotid junction was as effective as occlusion below this junction. It is concluded that there are at least two groups of receptors concerned with the regulation of the blood level of ADH within the vascular system: one group located in the carotid sinuses, and a second group with afferent nerve fibers in the vagi.

During constant pressure perfusion of the left coronary artery, stimulation of the peripheral cervical vagi produced a small but definite increase in coronary blood flow (CBF) in paced and nonpaced beating hearts and in fibrillating hearts. In the latter preparations flow increment was associated with an increase in coronary sinus blood pO 2 (CspO 2 ), changes similar to those elicited by intracoronary administration of acetylcholine. During constant pressure perfusion of the left coronary artery in paced and nonpaced beating hearts and in fibrillating hearts, stimulation of the stellate ganglia produced an initial decrease and subsequent increase in CBF. The increase in flow was associated in time with a reduction in CspO 2 in fibrillating hearts. The results obtained with stellate ganglion stimulation were reproduced by intracoronary administration of epinephrine. These observations indicate that the primary effect of vagus nerve stimulation on the coronary vasculature is vasodilation and that of stellate ganglion stimulation, constriction. The delayed increase in CBF seen with stellate ganglion stimulation is presumably secondary to the attending enhanced myocardial metabolic activity.

Abstract Background Gastric variceal bleeding carries significant mortality in the setting of portal hypertension. Among the endoscopic treatment options, endoscopic ultrasound (EUS)-guided glue and/or coil injection is a novel approach, but its role in the treatment of gastric varices is not established due to a lack of robust data. Methods We conducted a comprehensive search of several databases (inception to June 2019) to identify studies evaluating EUS in the treatment of gastric varices. Our primary goals were to estimate the pooled rates of treatment efficacy, obliteration and recurrence of gastric varices, early and late rebleeding, and adverse events with EUS-guided therapy in gastric varices. We also searched for studies that evaluated direct endoscopic glue (END-glue) injection for treatment of gastric varices, and used the pooled rates as comparators. Results 23 studies (851 patients) evaluating EUS-guided therapy were included. The pooled treatment efficacy was 93.7 % (95 % confidence interval [CI] 89.5 – 96.3, I 2 = 53.7), gastric varices obliteration was 84.4 % (95 %CI 74.8 – 90.9, I 2 = 77), gastric varices recurrence was 9.1 % (95 %CI 5.2 – 15.7, I 2 = 32), early rebleeding was 7.0 % (95 %CI 4.6 – 10.7, I 2 = 0), and late rebleeding was 11.6 % (95 %CI 8.8 – 15.1, I 2 = 22). The rates were comparable to END-glue therapy (28 studies, 3467 patients) except for obliteration, which was significantly better with EUS-guided therapy. On subgroup analysis, EUS-coil/glue combination showed superior outcomes. Conclusions EUS-guided therapy demonstrated clinical efficacy for treatment of gastric varices in terms of obliteration, recurrence, and long-term rebleeding, and may be superior to END-glue.

Abstract Background Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results. Methods We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence. Results 1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 – 85.5, I 2 = 29) and 88.1 % (95 %CI 83.6 – 91.4, I 2 = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 – 96.9, I 2 = 0) and 96.7 % (95 %CI 94.0 – 98.2, I 2 = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 – 99.1, I 2 = 0) and 89.3 % (95 %CI 86.6 – 91.5, I 2 = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 – 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 – 6.8) and 3.7 % (95 %CI 2.3 – 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 – 10.0). Conclusion EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.

Inasmuch as hereditary angioneurotic edema has generally been overlooked in the pediatric literature, it is hoped that this report may alert pediatricians to the possibiity of the existence of the disease in children of families with appropriate histories. It is likely that the symptomatology will not be severe in childhood; nonetheless, swellings and abdominal attacks do occur. Most important, the possibility that abdominal surgery will be helpful during bouts of abdominal pain due to hereditary angioneurotic edema should be considered unlikely. Markedly edematous viscera may provide technical difficulty during surgery, and undue physical trauma is not helpful. Hereditary angioneurotic edema differs from other non-allergic angioneurotic edema in that the tendency to attacks of edema is inherited as an autosomal dominant trait and swellings tend to be much more severe. The failure of anti-allergic medications and lack of evidence for allergy as a cause of attacks of hereditary angioneurotic edema tend to differentiate this disease from the more common allergic forms. Absence of serum inhibitor of C'lesterase further characterizes hereditary angioneurotic edema. Sera from persons with non-familial allergic and non-allergic angioneurotic edema have contained normal or greater than normal amounts of this inhibitor.7 In view of the definition of biochemical alterations in the blood of patients with hereditary angioneurotic edema and the possibility of identifying affected individuals before the onset of symptoms, it is to be hoped that a rational means for the prevention of symptoms can be devised.

Abstract A microprobe electrode was used to determine dissolved oxygen concentrations near the surface and within a bacterial slime mass supplied with a continuous flow of nutrient solution. With dilute medium, the oxygen profile became level at high concentrations within the film, indicating substrate‐limited respiration. More concentrated medium caused the profile to fall to low oxygen concentrations characteristic of oxygen‐limited respiration. Oxygen responses to sudden changes in concentration of nutrient medium were measured. Estimates of microbial respiration rate and of diffusivity of oxygen were based on well‐known diffusion equations.

Islam holds life as sacred and belonging to God and that all creatures will die one day. Suicide is forbidden. Muslims believe death is only a transition between two different lives. The terminally ill Muslim desires to perform five ritual requirements. Do not resuscitate (DNR) orders are acceptable. A deceased Muslim must always be buried after being ritually washed and wrapped. There are different Muslim schools of thought, but they are united regarding their views on death and dying.