Biomedical subjects
Publications and source records attributed to J Franco.
Reye's syndrome (RS), a condition characterized by encephalopathy and fatty liver, is associated with aspirin use and carries a poor prognosis. The majority of patients with RS are children and adolescents. We report a case of RS in an adult.
We have modeled the gas response to a spiral density wave (SDW) in a thick, magnetized galactic disk. The inclusion in the model of the vertically extended galactic warm ionized gas layer alters the conventional view of the SDW scenario for star formation: whereas marked density enhancements still occur in the midplane, the shock and a prominent high column density structure extend to high z (the height above the galactic midplane) above the arm. We argue that if the SDW mechanism indeed triggers molecular cloud and star formation, it should do so not only at the midplane but also at distances well above the star-forming thin disk of the conventional picture. The resulting structure resembles a hydraulic jump, or bore, in which gas entering the spiral arm rises suddenly on the upstream side of the arm, then accelerates and angles downward, finally landing on a large downfall region downstream of the arm.
The occurrence of hepatocellular carcinoma (HCC) in renal transplant recipients has typically been associated with hepatitis B or C infection. We encountered two cases of HCC in renal transplant recipients with negative hepatitis B and C markers and no underlying liver pathology, in whom immunosuppression therapy consisted of prednisone and azathioprine (AZA). Patient no. 1 is a 66-year-old man with diabetes who underwent cadaveric renal transplantation 13 years before presentation. An ultrasound obtained for evaluation of a prolonged prothrombin time and decreased serum albumin level showed a suspicious nodular lesion in the left lobe of the liver. A computed tomographic (CT) scan confirmed a 4- x 5- x 5-cm mass that, on biopsy, was determined to be well-differentiated HCC. There was no evidence of metastasis, and the results of random biopsies of the surrounding parenchyma were normal. The patient underwent a left lateral segmentectomy, did well, and an initial alpha-fetoprotein (AFP) level of 85995 ng/mL decreased to 9 ng/mL. Approximately 20 months postoperatively, however, a surveillance CT scan showed three hypervascular lesions in the right lobe of the liver and the AFP level increased to 28,370 ng/mL. Subsequent percutaneous alcohol injections yielded good results, and the patient is alive and well 13 months later. Patient no. 2 is a 57-year-old man who underwent cadaveric renal transplantation 24 years earlier. A CT scan of the abdomen obtained for evaluation of lower abdominal pain showed a 4- x 4- x 6.5-cm mass in the right lobe of the liver that, on biopsy, was found to be poorly differentiated HCC. Multiple biopsies of adjacent liver parenchyma showed no evidence of cirrhosis, AFP level was normal, and imaging studies showed no evidence of tumor spread. The patient underwent a right hepatic lobectomy and is doing well without evidence of recurrence 27 months postoperatively. Our two patients had no evidence of viral hepatitis, cirrhosis, or metabolic liver disease, yet both developed HCC. The use of AZA may have had a role in the development of HCC. In renal transplant recipients on long-term immunosuppression therapy, particularly AZA, it is prudent to maintain a high index of suspicion for HCC when liver enzyme level or function abnormalities are encountered.
Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) are chronic progressive cholestatic diseases that frequently lead to biliary cirrhosis. The exact pathogenesis of these diseases remains elusive but is likely immunologically based. Complications range from fatigue and pruritus to end-stage liver disease. The risk of developing hepatocellular carcinoma is low for patients with PBC, whereas cholangiocarcinoma is common in PSC and carries an ominous prognosis. Although ursodeoxycholic acid is effective in slowing the progression of PBC, no effective medical therapy exists for PSC. Liver transplantation is the only option for patients with end-stage liver disease and yields excellent long-term survival in both groups.
The treatment of patients with pruritus of liver disease poses a challenge to the clinician. Resins (cholestyramine or colestipol) in quantities of 4 to 16 grams a day should be the initial agents used. In those who remain refractory, diphenhydramine should be added, although sedation may limit the use of higher doses. If symptoms still persist, rifampin up to 600 mg/day can be added to the above regimen with close monitoring of hepatic function. If, despite this combination, pruritus persists and quality of life remains poor, experimental therapies in the form of oral opioid antagonists, and orthotopic liver transplantation should be considered.
Antileukotriene drugs are new therapeutic agents that have recently been approved for the treatment of asthma. Several cases of eosinophilic conditions including Churg-Strauss syndrome have been reported to be associated with zafirlukast, a cysteinyl leukotriene type 1 receptor antagonist. So far no other leukotriene modifier has been associated with the syndrome. The case history is presented of a man with allergic rhinitis and asthma who had received intermittent pulse therapy with oral corticosteroids. Pulmonary eosinophilia developed while he was receiving treatment with montelukast, a chemically distinct cysteinyl leukotriene type 1 receptor antagonist. After discontinuation of montelukast therapy and administration of systemic corticosteroids the patient's symptoms reversed rapidly and there was prompt resolution of the pulmonary infiltrates. We believe that cysteinyl leukotriene type 1 receptor antagonists are safe and effective drugs for most patients with asthma but caution is needed for those with more severe disease who require systemic corticosteroids, especially if they show characteristics of the atypical allergic diathesis seen in the prodromal phase of Churg-Strauss syndrome.
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The diagnosis of pulmonary sequestration traditionally requires arteriography to identify abnormal systemic vessels feeding the abnormal portion of the lung. Non-invasive imaging techniques have recently been used to replace arteriography. Conventional computed tomographic (CT) scanning is, however, at a disadvantage because of its inability to obtain multiplanar images. The combination of slip ring CT scanning and computerised three-dimensional reconstruction (spiral CT angiography) can be used to visualise the anatomical detail of a wide range of vessels within the lung. Four cases of pulmonary sequestration are reported which were successfully diagnosed using spiral CT angiography. Spiral CT scanning allows simultaneous imaging of anomalous vessels and lung parenchyma in a single examination and is particularly useful in the diagnosis and assessment of pulmonary sequestration.
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SETTING: Spain has the highest rates in Europe of the acquired immune-deficiency syndrome (AIDS), and probably a high rate of dual human immunodeficiency virus (HIV)/tuberculosis infection. OBJECTIVE: To determine the trends of tuberculosis mortality in Spain from 1970 to 1993, and to draw conclusions about the effects of the AIDS epidemic on these trends. DESIGN: Official population figures and data on deaths from tuberculosis were used to calculate specific tuberculosis mortality rates by age and sex (per 100000 population). Causes of death from tuberculosis were grouped according to the International Classification of Diseases. RESULTS: The crude death rate decreased from 10.28 to 1.84, with an annual mean decrease of 8.1% (95% confidence interval 7.5% to 8.7%). No changes in mortality from tuberculosis of the central nervous system (CNS) have been recorded since 1982, and none in mortality from other tuberculosis and in the age group 20-49 years since 1986. Mortality was higher among males and in the older age groups. The peak observed in the 1970s, due to the excess of deaths from CNS tuberculosis in children under the age of 5 years, has disappeared. CONCLUSION: Between 1970 and 1993, tuberculosis mortality in Spain decreased, although an excess of deaths occurred in young adults and from extra-pulmonary tuberculosis, coinciding with the AIDS epidemic.
The objective of the present study was to describe seasonal changes in scrotal circumference (SC), live weight (LW), sperm morphology and plasma levels of testosterone (T) and thyroxine (T4) in young Corriedale rams reared under extensive conditions typical for the southern Latin American region. A total of 31 Corriedale rams, 11 months of age and with a LW of 36 +/- 1.1 kg and (SC) of 23.0 +/- 0.5 cm at the beginning of the experiment (September) were kept on natural pastures. At monthly intervals LW was recorded, animals were clinically examined, and SC was measured. None of the animals were used for breeding. Fifteen animals were randomly selected and bled once a month from January to December and plasma concentrations of T and T4 were determined. In addition, one semen sample was collected by electroejaculation and morphological studies were performed. The mean individual LW increase was 18 kg (50% of the initial LW) during the experiment (p < 0.01). LW decreased in autumn, with the nadir in late autumn. SC reached mean maximum levels in late summer (31.1 +/- 0.4 cm, p < 0.01), then decreased until the beginning of winter (26.3 +/- 0.4 cm, p < 0.01) and remained low until early spring (27.5 +/- 0.5 cm, p > 0.05) to increase again between mid-spring and the end of the experimental period the following summer (30.7 +/- 0.5 cm, p < 0.01). The mean SC in winter was 16% lower than that in late summer. Semen could be collected from the rams throughout the experiment. Frequencies of sperm head, mid-piece and total abnormalities showed monthly variation (p < 0.05), but tail abnormalities were not affected by month. Low abnormalities were found in autumn (9.4% +/- 2.2%). T was high during autumn (p < 0.01). Minimal T4 concentrations were observed during late summer and early autumn (p < 0.01) when T levels were high. Maximum T4 concentrations were registered in late autumn (p < 0.01); when SC was decreasing; in mid-spring (p < 0.01) one month after shearing and in early summer (p < 0.01). The results suggest that Corriedale rams under Uruguayan extensive management systems show a reproductive seasonality that, in general terms, coincides with photoperiodic variations.
OBJECTIVE: To identify the situations that influence in the delayed diagnosis of tuberculosis. PATIENTS AND METHOD: We studied 109 patients (87 non HIV-infected and 22 HIV-infected) who were diagnosed of tuberculosis in one year consecutively, using a questionnaire to obtain time intervals in which the whole diagnostic delay (WD) was divided. RESULTS: WD was higher than 1 month in 90 % of non HIV-infected patients. The delay due to the health system (SD) was higher (71% > 1 month) than the delay due to patient (PD; 30% > 1 month) and there was a negative correlation between both (R-0.73). In HIV+ group, WD was lower (59.1% > month) and, although PD was higher (40.9% > 1 month), the time that the system delayed the suspicion of the diagnosis was lower (5.5% > 1 month). In HIV-group there were the following significant differences: higher delay in the suspicion of diagnosis (DSD) (61.4% and 60.8% > 1 month) and shorter time to make the diagnosis (12.3% and 21.6% > 1 month) in sputum smear-positive patients and who had cavitary lesions; PD was higher (67.1% > 1 month) in patients with general symptoms and nearly none in patients with upper airways symptoms; and higher DSD in presence of nonspecific symptoms like cough or/and expectoration (68.6% > 1 month) or upper airways symptoms (100% > 1 month). As these clinical symptoms were consulted in primary care mainly, there was a higher SD (75.75 > 1 month) and DSD (58.1% > 1 month), and were increased when a promptly chest X-ray was not performed (87.1 and 68.7% > 1 month). CONCLUSIONS: Delayed diagnosis of tuberculosis is common. In non HIV-infected patients, it occurs mainly in the health system. Diagnostic delays contribute to raise advanced disease with more contagious potential.
Combination therapy with zidovudine and recombinant human granulocyte-macrophage colony stimulating factor (rHu GM-CSF) may be warranted, owing to the bone marrow suppressive effects of zidovudine. A study of 16 patients, 8 of whom had acquired immune deficiency syndrome (AIDS) and 8 of whom were infected with human immunodeficiency virus (HIV) but were asymptomatic, was conducted. The effect of 4 days of rHU GM-CSF versus placebo on intermittent zidovudine therapy (200 mg every 8 hours) was evaluated using a randomized, cross-over study design. Pharmacokinetics of oral and intravenous zidovudine were determined on days 1 (oral), 3 (oral), and 4 (intravenous) of rHu-GM-CSF (placebo) administration. After intravenous dosing, zidovudine plasma clearance for placebo and rHu GM-CSF averaged 1.4 +/- 0.2 and 1.3 +/- 0.2 L/hr/kg, respectively (P = 0.017), mean residence time averaged 1.5 +/- 0.5 and 1.9 +/- 0.6 hours, respectively (P = 0.012), and the steady-state volume of distribution was 2.0 +/- 0.7 and 2.3 +/- 0.7 L/kg, respectively (P = 0.027) for the two treatment arms. Stratified data for patients with AIDS and those with asymptomatic HIV infection revealed no significant difference in plasma clearance or mean residence time between the two patient groups. These pharmacokinetic results indicate that dosage adjustments for zidovudine are not warranted when administered with rHu GM-CSF owing to the small changes observed. However, the statistically significant increase in Vss suggests the possibility of enhanced zidovudine cellular uptake in the presence of rHu GM-CSF.
Chronic eosinophilic pneumonia (CEP) is characterized by non-specific clinical presentation, interstitial radiological signs, peripheral acini and pulmonary infiltration by eosinophils, accompanied or not by peripheral eosinophilia. Response to treatment with steroids is spectacular. We describe 4 patients with CEP, one diagnosed by response to treatment and the others by bronchoalveolar lavage (BAL). No patient had asthma; 1 also had peripheral eosinophilia. All received long-term treatment with steroids, and there were no relapses. Response to treatment was slow in 2 patients, but obliterans bronchiolitis with or without organizing pneumonia could not be demonstrated. We emphasize the safety and efficiency of BAL for diagnosis of CEP.
A liver transplant patient with previous episodes of diarrhea and pseudomembranous colitis due to Clostridium difficile subsequently developed pseudomembranous colitis due to cytomegalovirus. The patient responded to ganciclovir. Cytomegalovirus infection should be considered in the differential of pseudomembranous colitis in immunocompromised patients, particularly when C. difficile toxin assays or cultures are negative.
Severe hypoxemia is an uncommon feature of hepatic cirrhosis. Its major cause are intrapulmonary arteriovenous shunts, both due to direct arteriovenous communications and abnormally dilated pulmonary capillaries. In the present study, a case of cirrhosis associated with severe hypoxemia is reported. Contrast echocardiography showed pulmonary arteriovenous shunts, and low values of mixed venous blood (15% or less were obtained with the method of 100% oxygen breathing). These data suggest that the basic mechanism of hypoxemia, in this case, were capillary dilatations rather than true pulmonary arteriovenous anastomoses. The pathophysiological mechanisms of hypoxemia in cirrhosis are discussed, with emphasis on the present relevance of echocardiography for a full evaluation of these patients, particularly when liver transplantation is contemplated.
Quality assurance, an issue receiving great attention in medicine of late, has its origins in the consumerism of the mid 60's and in the budgetary problems which became more pronounced following the oil embargo of the 1970's. Consumerism, initially concerned with product safety, eventually extended to the patient/doctor relationship. Physicians became providers of healthcare, and as such were increasingly viewed as liable for the results of that care. A bad result implied bad care. The rate of malpractice claims began to increase, with a concomitant increase in malpractice insurance premiums. This upward pressure on medical costs came at a time of economic crisis, related in part to increasing oil costs, competition from foreign manufacturers, and rising national debt. It was inevitable, therefore, that those who pay for medical care (private insurers and the government) would look for ways to ensure that the care they were buying was both necessary and of good quality.
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