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Biomedical subjects

J J Kelly

Publications and source records attributed to J J Kelly.

At least 91 records · Page 5Linked to original sources
PubMed1994

Nerve conduction and biopsy correlation in over 100 consecutive patients with suspected polyneuropathy.

Neuropathy was classified physiologically and histologically as normal, axonal, demyelinative, or indeterminate using specific motor nerve conduction (NC) and sural sensory nerve biopsy (NB) criteria. Physiological and histological diagnoses were concordant in 63%, and minimally discordant in 14% of patients. The most important discordant patients were 6 with demyelinative neuropathy, 4 by NC, of which 2 were pure motor syndromes, and 2 by NB, both predominantly sensory syndromes. In the 55 patients with predominant axonal degeneration on biopsy, the extent of NC slowing was determined. As compound motor and sensory nerve action potential (CMAP and SNAP) amplitude declined, distal motor latency increased, whereas motor and sensory conduction velocity (CV) did not. Minimum F response latency increased as motor CV decreased, more in lower than upper extremity nerves. We conclude that: (1) except for sensory neuropathy, routine motor NC studies generally suffice in identifying demyelinative neuropathy; (2) NC slowing in axonal neuropathy is usually slight but may result in significantly prolonged distal motor latencies when CMAP amplitude is very low, and prolonged F wave latency when motor CV is slightly low; and (3) The physiologic criteria employed in this study rarely misclassifies neuropathy as demyelinative in patients with predominant axon loss on biopsy.

Action Potentials↗
PubMed1994

Body composition and energy expenditure in acromegaly.

To investigate whether GH is a regulator of body composition and energy metabolism in adult life, we have compared body composition and resting energy expenditure (REE) in a cross-sectional study in 20 acromegalic and 20 normal subjects, pair-matched for sex, age, height, and weight. In a longitudinal study, 8 acromegalic patients were also studied before and after 12 weeks of treatment [n = 6 during octreotide (100 micrograms, 3 times/day); n = 2 after pituitary surgery], and 7 patients were studied 12 weeks after withdrawal of octreotide. REE was measured by indirect calorimetry and fat mass and fat-free soft tissue mass (FFSTM) by dual energy x-ray absorptiometry. A subgroup of 12 matched pairs of subjects and 7 treated patients had measurement of extracellular water (ECW) by 24Na dilution, which when subtracted from FFSTM provided an estimate of body cell mass (BCM). Fat mass was significantly reduced (25.4 +/- 2.2 vs. 29.7 +/- 2.7 kg; P = 0.007) and FFSTM increased (53.3 +/- 2.2 vs. 49.2 +/- 2.3 kg; P = 0.003) in acromegaly with ECW (25.6 +/- 1.6 vs. 21.1 +/- 0.9 L; P = 0.0003), but not BCM, significantly elevated. Treatment of acromegaly increased fat mass and reduced FFSTM [change (delta), -1.3 +/- 0.4 kg; P = 0.004]; the latter reflected a significant fall in ECW (delta, -2.2 +/- 0.4 L; P = 0.002), but not BCM. The opposite effect on body composition occurred after treatment withdrawal. REE was increased in acromegaly (1682 +/- 49 vs. 1540 +/- 45 Cal/24 h; P = 0.02) and significantly related to insulin-like growth factor-I (P = 0.02). REE was significantly reduced (delta, -154 +/- 17 Cal/24 h; P = 0.0001) with treatment and increased after treatment withdrawal (P = 0.003). In acromegaly, there is a reversible 1) reduction in fat mass; 2) increase in FFSTM, accounted for by an increase in ECW, but not BCM; and 3) increase in REE, which is dependent on disease activity. We conclude from these observations in acromegaly that GH is a regulator of energy metabolism and body composition.

Absorptiometry, Photon↗
PubMed1994

Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans.

The purpose of this study was to determine differences in the use of total knee arthroplasty for osteoarthritis among black and white older Americans and to determine whether clinical and economic factors contribute to these differences. Data on black and white Americans aged 65 years and older were gleaned from national Medicare hospitalization records for 1980 through 1988 and the Medicare enrollment file for 1987, the First National Health and Nutrition Examination Survey of 1971 through 1975, the National Hospital Discharge Survey of 1979 through 1988, the 1980 through 1988 US census counts and estimates, and 1980 census economic data. Information gathered includes prevalence of osteoarthritis of the knee among blacks and whites; rate of total knee arthroplasty use in the United States by race, sex, and age of subjects at the time of operations; use of competing procedures; and economic factors. Results showed that blacks were less often treated with total knee arthroplasty than were whites (white-to-black rate ratios = 3.0 to 5.1 for men and 1.5 to 2.0 for women) but had nonsignificantly higher rates of clinical osteoarthritis of the knee (white-to-black rate ratios = 0.39 for men and 0.78 for women). This racial difference in total knee arthroplasty rates was consistent across income levels and was unexplained by black patients' having operations at earlier ages or using competing procedures. Furthermore, the discrepancy occurred even among Medicaid-eligible Medicare recipients, who had no direct economic disincentive for surgery. These findings suggest that even though elderly blacks have higher rates of knee osteoarthritis, they do not receive total knee arthroplasty as often as do elderly whites. This discrepancy does not appear to have an economic explanation. Even if a comprehensive care system were in place to remove economic barriers, inequality in the use of this procedure would likely persist. Future studies should assess the nonclinical and noneconomic causes of these differences.

Black or African American↗
PubMed1993

Effects of different oral oestrogen formulations on insulin-like growth factor-I, growth hormone and growth hormone binding protein in post-menopausal women.

OBJECTIVE: Insulin like growth factor-I (IGF-I) levels in post-menopausal women are reduced by oral administration of the synthetic oestrogen ethinyl oestradiol but increased by transdermal delivery of 17 beta-oestradiol. Since these oestrogen types are different, the aim of this study was to clarify whether reduction in IGF-I is a specific effect of ethinyl oestradiol or common to other oral oestrogen formulations. DESIGN: Randomized cross-over study comparing one month of treatment with ethinyl oestradiol (20 micrograms), conjugated equine oestrogen (1.25 mg Premarin) and oestradiol valerate (2 mg). SUBJECTS: Six healthy post-menopausal women, age 60.3 +/- 5.6 years. MEASUREMENTS: Mean 24 hour GH (from hourly sampling), IGF-I, GH binding protein (GHBP), pituitary (LH, FSH) and hepatic function (SHBG and angiotensinogen) were measured. RESULTS: All three oestrogen formulations resulted in a significant reduction in IGF-I levels compared to baseline and significant elevations of GH and GHBP (P < 0.05). The percentage increase in GH during oestrogen treatment was significantly related to the percentage decrease in IGF-I levels (P = 0.04). All three oestrogen formulations resulted in significant suppression of LH and FSH and induction of the hepatic proteins, SHBG and angiotensinogen (P < 0.05). GHBP increased in parallel with other hepatic proteins. CONCLUSIONS: Reduction in IGF-I levels is an intrinsic effect of oral oestrogen therapy and increased GH levels may occur as a result of reduced feedback inhibition by IGF-I. Since GHBP activity is not changed by transdermal oestrogen, we conclude that the liver is a major source of circulating GHBP and that GHBP is an oestrogen sensitive protein.

Aged↗
PubMed1993

Polyneuropathy associated with monoclonal gammopathy of undetermined significance: further evidence that IgM-MGUS neuropathies are different than IgG-MGUS.

We evaluated the clinical characteristics and electromyographic features of 39 patients with monoclonal gammopathy of undetermined significance (MGUS) and neuropathy. Twenty-three patients had a monoclonal IgM protein, 13 had an IgG, and three had an IgA. In 15 patients of the IgM group, the M protein reacted with myelin-associated glycoprotein (MAG). Comparing IgM-MGUS and IgG-MGUS neuropathies, we found the following differences: (1) There was a statistically significant higher frequency of sensory loss in the IgM group. (2) Nine attributes of nerve conduction abnormality were statistically worse in the IgM group, with slowing of conduction velocities and prolonged distal latencies. (3) The frequency of monoclonal IgM was overrepresented in the MGUS neuropathy group. In general, the clinical and electrophysiologic features of the IgM-MGUS MAG-reactive group were not significantly different than the MAG-nonreactive group. Our cases are similar to those previously reported and suggest that monoclonal IgM-MGUS should be separated conceptually from monoclonal IgG neuropathies.

Adult↗
PubMed1993

AIDS deaths shift from hospital to home. AIDS Mortality Project Group.

OBJECTIVE: This study monitors trends in place of death among persons with acquired immunodeficiency syndrome (AIDS) as a measure of health care usage patterns and terminal health care among persons infected with human immunodeficiency virus (HIV). METHODS: Sixteen health departments collected death certificates for 55,186 persons with AIDS whose deaths occurred through 1991. Place of death was categorized as hospital, residence, hospice or nursing home, and other. RESULTS: The percentage of AIDS deaths at hospital facilities decreased from 92% in 1983 to 57% in 1991. In 1988, 23% of deaths occurred at home or in hospices and nursing homes. This trend was more evident among men, Whites, and men who had sex with men; less so among persons with other modes of exposure; and not at all among injecting drug users and children with perinatally acquired AIDS. Place of death varied by geographic location, with the greatest percentage of hospital deaths in the Northeast (91%) and the greatest percentage of at-home deaths in the West (27%). CONCLUSIONS: The percentage of AIDS deaths at home or in hospices and nursing homes has increased since 1983. These trends may reflect changes in hospital use for end-stage HIV infection. Decreasing hospitalization and increasing outpatient services and home care will decrease costs and may allow HIV-infected persons improved social support.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Evaluation of the reproducibility and accuracy of ambulatory blood pressure monitoring using the Takeda TM-2420 automated blood pressure monitor.

The reproducibility of ambulatory blood pressure measurements was assessed in eight normotensive subjects who underwent three separate days of recording, using Takeda Medical TM-2420 (TM-2420) blood pressure monitors. The coefficients of variation of mean 24 hour systolic and diastolic blood pressure were 2.1% and 2.8% respectively. The corresponding values for systolic and diastolic blood pressure variability, were 19% and 14% respectively. Measurement intervals of greater than 30 minutes significantly reduced the reproducibility of mean day interval systolic measurements. The bias of the TM-2420 systolic and diastolic blood pressure measurements compared to standard sphygmomanometer measurement were 0 +/- 7 mmHg and 1 +/- 6 mmHg respectively. Ambulatory blood pressure monitoring provides reproducible estimates of mean systolic and diastolic blood pressure, however, blood pressure variability is poorly reproducible.

Adaptation, Physiological↗
PubMed1992

Pulmonary hypertension predicts mortality and morbidity in patients with dilated cardiomyopathy.

OBJECTIVE: To ascertain whether pulmonary hypertension, as assessed noninvasively by continuous-wave Doppler of tricuspid regurgitation, can be an important independent factor in the prognosis of patients with ischemic or idiopathic dilated cardiomyopathy. DESIGN: Cohort study of consecutive patients with dilated cardiomyopathy in whom follow-up was obtained on all survivors for 28 months. SETTING: Outpatient cardiology private practice office in a tertiary care center. PATIENTS: Consecutive sample of 108 patients who presented for a scheduled office visit during a 15-month period. MEASUREMENTS: M-mode, two-dimensional, and Doppler echocardiographic examinations were done on all patients at entry into the study and on survivors 1 year later. All examinations included extensive pulsed- and continuous-wave Doppler evaluation for tricuspid regurgitation. MAIN OUTCOME MEASURES: Overall mortality, mortality due to myocardial failure, and hospitalization for congestive heart failure. RESULTS: Twenty-eight patients had a high velocity of tricuspid regurgitation (greater than 2.5 m/s), and 80 patients had a low velocity (less than or equal to 2.5 m/s). After 28 months of follow-up, the mortality rate was 57% in patients with a high velocity compared with 17% in patients with a low velocity (difference of 40%, 95% CI, 20% to 60%). Hospitalization for congestive heart failure occurred in 75% and 26% of patients, respectively (difference of 49%, CI, 30% to 68%). Eighty-nine percent of patients with a high velocity either died or were hospitalized compared with only 32% of patients with a low velocity (difference of 57%, CI, 42% to 72%). The peak velocity of tricuspid regurgitation was the only prognostic variable selected using stepwise logistic regression models for the three outcome events. CONCLUSION: Noninvasive assessment of pulmonary hypertension using continuous-wave Doppler of tricuspid regurgitation can predict morbidity and mortality in patients with ischemic or idiopathic dilated cardiomyopathy.

Adult↗
PubMed1992

Cell specificity of transcription regulation by papovavirus T antigens and DNA replication.

Simian virus 40 (SV40) and polyomavirus (Py) DNA replication require cellular proteins and a virus-encoded early gene product, large T antigen (SVT and PyT, respectively). Primate cells contain factors permissive for SV40 replication, whereas murine cells express those factors permissive for Py. We have compared the roles T antigen, cell permissiveness and replication play in transcription of SV40 and Py genes. We show that in their respectively permissive cells, SV40 replication causes a major shift in transcription initiation from the early to the late viral promoter, whereas when Py replicates a comparable shift does not occur. This difference is discussed in relation to differences in the organization of the origin and promoter region between these two papovaviruses. Reporter plasmids were constructed that carried both viral origins, one at the natural position in the promoter being tested and the other at a distal location. With the appropriate TAg, these vectors could be made to replicate in either primate (HeLa) or rodent (3T6) cells. The SV40 early to late shift occurred when replication was driven in HeLa cells, and was not seen on replicating templates in rodent cells. Thus, replication per se does not account for the shift. We show also that, like SVT, PyT is a potent activator of transcription, and that SVT and PyT can activate each other's late promoters independently of DNA replication, but only in cells permissive for DNA replication catalysed by the respective T antigen. Taken together, the data presented here suggest that papovaviruses may utilize permissive factors in transcription control mechanisms.

Animals↗
PubMed1992

Impact of an emergency medicine residency program on the quality of care in an urban community hospital emergency department.

STUDY OBJECTIVES: To assess the impact of the introduction of an emergency medicine residency program on the quality of care in an urban community hospital emergency department. DESIGN: A retrospective chart review of all ED encounters for a three-month period beginning six months before and six months after the introduction of an emergency medicine residency. SETTING: A 27,000-visit-per-year urban community hospital ED. TYPE OF PARTICIPANTS: All patients who presented to the ED with one of five complaints and subsequently were discharged home. The five presenting categories examined were nontraumatic chest pain when age 30 years or more, lower abdominal pain in women aged 15 to 40 years, recent head trauma, headache of nontraumatic origin, and extremity laceration. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The frequency of physician documentation on the ED record of explicit criteria related to the five presenting complaints was used as a measure of the quality of care. Items sought for documentation included elements of the history and physical examination and diagnostic evaluations. The explicit criteria lists were drawn from the literature, including clinical policy guidelines. For each of the presenting complaints evaluated, documentation of the majority of items reflecting the quality of care was higher during the residency period. In no instance did the level of documentation decrease. CONCLUSION: As measured by a process evaluation, documentation of the medical record, the introduction of an emergency medicine residency significantly improved the quality of care in this urban community hospital ED.

Abdominal Pain↗
PubMed1992

Cost of care in the emergency department: impact of an emergency medicine residency program.

STUDY OBJECTIVE: To evaluate the impact of an emergency medicine residency training program on the cost of care in the emergency department. DESIGN: A retrospective chart review was conducted of all ED encounters for a three-month period, six months before and six months after the introduction of an emergency medicine residency program into an urban community hospital. Physician staffing of this ED before the residency period was by nonemergency medicine residency-trained emergency physicians. SETTING: A 27,000-visit-per-year urban community hospital ED. TYPE OF PATIENTS: A consecutive sample of all patients discharged home from the emergency center with one of six diagnoses. The diagnoses studied were viral upper respiratory infection, pharyngitis, acute asthma, seizure, lumbosacral strain, and cervical strain. MAIN OUTCOME MEASURES: Frequency of laboratory test and radiograph ordering pertinent to the evaluation of each diagnostic category were used as a marker of cost of care. RESULTS: The presence of the residency training program did not increase the cost of care as measured by test use and, for three of the six diagnoses, actually lowered the cost of care. This effect was most prominent in the evaluation of lumbosacral and cervical strain when the residency physicians ordered radiographs at a rate five and 2.3 times lower, respectively, than the previous group and in the approach to pharyngitis when they ordered throat cultures 2.8 times less frequently. CONCLUSION: As measured by selected test use for six common discharge diagnoses, the introduction of an emergency medicine residency program did not increase the cost of care in this urban community hospital ED.

Adolescent↗
PubMed1992

The dropped head syndrome.

We describe four patients with a neuromuscular syndrome characterized by relatively isolated neck extensor weakness. EMG and muscle biopsies suggest a restrictive noninflammatory myopathy predominantly affecting the cervical paraspinal muscles.

Aged↗
PubMed1991

Role of the SV40 enhancer in the early to late shift in viral transcription.

Simian virus 40 large tumor antigen is a multifunctional protein, with two of its roles being the promotion of viral DNA replication and replication-independent activation of viral transcription. Replication leads to a shift in transcription from the early-early to the late and late-early cap sites, through mechanisms poorly understood. The viral transcription enhancer contains sequences important for both early and late transcription, and we therefore have carried out experiments to evaluate its role in these events. We find that the ability of replication to lead to a shift diminishes when early-early transcription is made increasingly stronger by multimerizing the enhancer, and suggest that replication might lead to the shift by interfering with the ability of the enhancer to direct initiation to those sites. The natural situation in the virus of having two copies of this element might represent a compromise between maximizing both T antigen expression early in infection and late gene expression after replication begins. We also show that replication-independent transcription activation by T antigen is bidirectional and involves at least in part elements to which the factor TEF-1 binds.

Antigens, Polyomavirus Transforming↗
PubMed1991

Role of electromyography in amyotrophic lateral sclerosis.

We reviewed the role of electrodiagnostic testing in amyotrophic lateral sclerosis (ALS) in a large ALS clinic. Over 31 months, 133 patients with a clinical diagnosis of ALS were tested. In most, nerve conduction studies were normal, and needle electrode examination showed active denervation in the upper and lower limbs or the limbs and bulbar muscles (Lambert's criteria). However, 50 of 133 patients did not fulfill Lambert's criteria at presentation because of abnormal nerve conduction studies (11 patients), abnormal F-wave latencies (6 patients), or insufficiently distributed fibrillation potentials (40 patients). This study reveals that a large proportion of patients with a clinical diagnosis of ALS fail to have classical findings on initial electrodiagnostic studies, and reveals several caveats of electrodiagnostic testing in these patients: (1) Conduction studies may be unreliable in motor nerves with markedly low compound muscle action potential (CMAP) amplitudes. (2) Sensory nerve action potential (SNAP) amplitudes may be abnormal in a small percentage of otherwise typical ALS patients. However, better controls for elderly subjects are needed. (3) Needle electrode examination may not show widespread active denervation early in the disease. (4) Some patients may have a mild polyneuropathy. (5) The classic diagnostic criteria may need to be modified to allow earlier acceptance of many ALS patients into therapeutic trials.

Action Potentials↗
PubMed1991

Role of growth hormone in fluid homeostasis.

Administration of human growth hormone (GH) is associated with clinically significant sodium retention. There is evidence that the antinatriuretic properties of GH are mediated by activation of the renin-angiotensin system, as well as a direct action on the kidney. The antinatriuretic properties of GH may be of pathophysiological significance in acromegaly, where increased body sodium and plasma volume occur, and may contribute to the development of hypertension in this condition.

Growth Hormone↗
PubMed1991

Massive orofacial abscesses of dental origin.

Massive cervicofacial abscesses of dental origin are relatively rare, and may be associated with serious and grave morbidity. In extreme cases, an occasional fatality may result from regional complications. Three cases are presented that describe the clinical and radiographic evaluation and the surgical approaches for abscess drainage. Specific attention is directed toward 1) the management of imminent airway obstruction, 2) the application of computed tomographic technology for localization and surgical planning, and 3) current antibiotic therapy.

Abscess↗