Biomedical subjects
Publications and source records attributed to R L Jacobs.
Diabetes is the most common cause of foot insensitivity. Its treatment requires in depth education of the patient in the cause, effects, and danger signs of the disease. Circulatory studies are outlined with particular emphasis on the use of the ultrasonic Doppler in monitoring the course of any foot lesions particularly with regard to their healing.
Six diabetic patients with a large, resistant ulcer on the plantar surface of the great toe were treated by resection of the proximal one-half of the proximal phalanx of the great toe through a dorsal median incision followed by a split-thickness skin graft onto the ulcer bed. Each of these ulcers had failed to heal with conservative measures which included debridement, split-thickness skin grafts, and extra-depth shoes with molded insoles. Preoperatively each patient had a complete vascular evaluation and appropriate antibiotic treatment. Postoperatively the ulcers healed promptly, and no ulcers had recurred at follow-up after two to five years. The only complication was delayed healing of the incision in one patient. At follow-up no obvious functional impairment of gait was evident, and each patient had regained his or her original functional status.
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Fifty-two patients with perennial nasal symptoms of sneezing paroxysms, profuse watery rhinorrhea, and pruritus of the nasopharyngeal mucosa in an "on-again-off-again" symptomatic pattern have been clinically and immunologically characterized. Historically, age at onset of symptoms showed equal distribution from the first through the fifth decades, and the duration of symptoms at diagnosis ranged from 3 mo to 40 yr (mean 9 yr). Trigger factors associated by the 52 patients with the acute onset of nasal symptoms were none or unknown in 22 (42%), weather changes in 16 (31%), odors in eight (15%), and noxious or irritating substances in six (12%). No patients had a history or physical examination consistent with nasal polyposis, bronchial asthma, current sinusitis, nor otitis media. Fifty percent had a negative family history for either chronic rhinitis or bronchial asthma. Nasal secretion smears revealed marked eosinophilia during symptomatic periods. Intradermal skin tests were negative in 49 patients. Serum radioallergosorbent test (RAST) confirmed immediate hypersensitivity skin tests in two of the three patients with positive skin tests. Mean total eosinophil count was 218/mm3. Quantitative immunoglobulins were normal in all patients. Mean serum IgE was 74 IU/ml. Methacholine bronchial challenge was negative in 37 of 37 patients tested. An open aspirin challenge was negative in 13 of 13 patients tested. Spontaneously collected nasal secretions or 0.9% saline nasal washes were analyzed for percent eosinophils, total protein, IgG, IgA, IgE, and RAST to six perennial aeroallergens in 31 of the 52 patients. Neither elevated total IgE nor evidence of specific IgE was found in the study patients' nasal secretions. This report describes 52 patients with symptoms similar to those seen in perennial allergic rhinitis. A characteristic pattern of symptomatic presentation and a paucity of the in vivo and in vitro findings associated with IgE-mediated nasal disease distinguishes this homogeneous disorder from perennial allergic rhinitis.
Anaphylaxis to known allergens occurred in two patients under treatment for hypertension with propranolol. The clinical course of both cases was similar. Bradycardia associated with an undetectable blood pressure, unusual severity, and sluggish response to treatment were major common factors in which blockade of the beta-adrenergic system may have had a role. Propranolol, a beta-adrenergic antagonist that acts competitively by blocking the adenylate cyclase receptor on efferent cells, is well recognized to cause increased airways resistance in some asthmatic and normal subjects. It is postulated that propranolol potentiated anaphylaxis in these patients by inhibition of adenylate cyclase, resulting in lowered intracellular cyclic AMP and a lowered threshold of mediator release. The bradycardia during profound hypotension is attributed to an unopposed cholinergic action caused by blunting of the normal endogenous beta-adrenergic response by propranolol.
Specific immune serum was found to inhibit the dispersal of the merozoites from mature schizonts, thus interfering with their subsequent reinvasion of new host erythrocytes. This phenomenon is viewed as a protective mechanism against malaria which can be measured in vitro and reflects the immune status of the donor.
In review of our data, 12 of 38 patients (31.5 percent) had adverse drug reactions, a somewhat bothersome factor. Disturbing side effects of leukopenia and pancytopenia were seen in two patients, respectively, who were receiving cefamandole 12 g/d. Other cephalosporins, including cephalothin and cefazolin, have been reported to cause leukopenia. Eosinophilia and elevations of alkaline phosphatase and SGOT levels were noted with other cephalosporins. We observed no adverse clinical reactions associated with these findings. Although our study was able to demonstrate the therapeutic effectiveness of cefamandole in the treatment of soft tissue and skeletal infections, it should be reemphasized that cefamandole should be used only as an alternative treatment for the penicillin-allergic patient. In reality, a first-generation cephalosporin should be used for gram-positive organisms if one is required in soft tissue infections.
With improved methods of medical care, the survival rates in all types of diabetes are improving. There are increasing numbers of older diabetics with complicated soft tissue problems. This is a report of our experiences in treating 15 consecutive patients with soft tissue defects involving the hindfoot. Each of these patients had an intact forefoot.
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A system with continuous flow of medium that uses disposable tissue culture flasks for the in vitro cultivation of P. falciparum is described. This scaled-up modification of the Trager and Jensen method gives merozoite yields sufficient for experimental vaccine studies in animals. A method of increasing the yield of merozoites by decreasing the pH of the medium is presented.
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Various problems encountered in dealing with diabetic feet are discussed from the point of view of the orthopedist, the vascular surgeon, and the specialist in infectious disease. In our hospital, each new diabetic patient with a compromised extremity is evaluated by the team, and joint decisions are made concerning therapy. Treatment may be tedious and time consuming, but under these optimum conditions, we feel our salvage rate has been much improved. When it is realized that 30 percent of all diabetics with an amputation of one extremity come to amputation of the other extremity within three years, the rationale for this additional attention and care becomes obvious.
A 38-year-old physician developed polyuria and hypodipsia four days after the onset of an upper respiratory tract infection. Subsequent investigation showed a concentration defect with dehydration that partially corrected with vasopressin injection (Pitressin) administration compatible with partial central diabetes insipidus (DI). Skull roentgenograms, EEG, and lumbar puncture were normal. The polyuria and hypodipsia slowly resolved without treatment. Normal urinary concentration ability was achieved by the 48th day, but a residual elevation in serum osmolarity persisted for one year. Review of the literature failed to show previous documentation of transient DI with elevated serum osmolarity from an acute, febrile illness. The mechanism is speculative, but may be related to a subclinical encephalitis. The true frequency of this syndrome and its relationship to the frequent observation of transient polydipsia and polyuria in "benign" febrile illness remains to be determined.
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It is now apparent that venom and venom components of the Hymenoptera superfamilies of Apida (honeybee) and Vespida (wasps, yellow jackets, and hornets) are becoming increasingly important in the diagnosis and treatment of hypersensitivity reactions. Stings from fire ants (superfamily Formicidae, family Myrmicinae) have also been recognized as causes of systemic reactions in man. Fire ant venom is unique in its composition, consisting mainly of alkaloids in aqueous suspension with only trace amounts of protein. This study compares the skin reactivity of fire ant venom and synthesized alkaloid components with the whole body extract (WBE) of fire ants and other Hymenoptera. The venom as well as the WBE of fire ants was found useful for skin test diagnosis of sensitive individuals. There appear to be cross-reactive or shared antigens between fire ant venom, WBE, and WBE of other Hymenoptera. Successful passive transfer of skin reactivity to nonsensitive individuals was accomplished with sera from sensitive individuals. Loss of this passive transfer by heating sera at 56 degrees C for 4 hr is evidence in favor of IgE mediating the positive skin test to the venom.
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