text stringlengths 170 4k | label int64 0 4 |
|---|---|
Vertebrobasilar occlusion following minor trauma in an 8-year-old boy. An 8-year-old boy developed seizures and coma 2 days after a trivial bicycle accident. Computed tomography failed to show pathology. Magnetic resonance imaging of the head showed infarction of the pons and right cerebellum. Angiography showed occlusion of the right vertebral and basilar arteries. Minor traumatic injuries to the cervical spine may result in vertebrobasilar occlusion. The neurologic manifestations of this disorder and emergency department diagnosis and management are discussed. | 3 |
Acute pelvic inflammatory disease after surgical sterilization. STUDY OBJECTIVE: Physicians are very cognizant of the possibility of pregnancy after surgical sterilization, but the potential for acute pelvic inflammatory disease (PID) is thought to be rare. This study was undertaken to determine if upper tract PID occurred more frequently than previously reported in patients remote from surgical sterilization. DESIGN: Retrospective review of hospitalized patients with the primary discharge diagnosis of PID. SETTING: Urban, university hospital. PARTICIPANTS: Three hundred sixty-four hospitalized patients with the primary discharge diagnosis of PID over a six-year study period. MEASUREMENTS AND MAIN RESULTS: Patients' age; gynecologic histories and diagnoses; and laboratory, clinical, and surgical findings were noted. Twenty-three cases of acute PID were identified in 21 patients previously sterilized (6%). Nine of the 23 cases had systemic toxicity warranting surgical evaluation; 18 of the 23 cases were admitted from the emergency department. Mean statistical characteristics of the study group were age, 27.3 +/- 0.8 (SE) years; time interval from sterilization, 49.8 +/- 7.4 months; WBC 15,000 +/- 1,200; and temperature, 38.0 +/- 0.2 C. CONCLUSION: We conclude that acute PID may occur more frequently than previously reported in patients with prior surgical sterilization. An increased awareness of this entity is warranted. | 4 |
Effects of nimodipine on cerebral blood flow and neuropsychological outcome after cardiac surgery. Thirty-five patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) were allocated randomly in a prospective double-blind study to receive either nimodipine 0.5 micrograms kg-1 min-1 or placebo. Cerebral blood flow (CBF) was measured during and immediately after CPB. Neuropsychological tests were performed 6 months after surgery to determine any relationship between ischaemic damage and CBF and administration of nimodipine. There were no differences in CBF between the nimodipine (n = 18) and placebo groups (n = 17). Significant changes in neuropsychological tests were found in six patients tested 6 months after surgery but there were no conclusive signs of ischaemic damage. The nimodipine-treated group performed better in tests of verbal fluency and visual retention, suggesting that some memory functions were preserved better in this group. | 4 |
Area of lateral ventricles measured on cranial ultrasonography in preterm infants: association with outcome. The association between measurements of lateral ventricle area (determined by serial ultrasound scans) and outcome was studied in 70 preterm neonates of 33 weeks' gestation or less. The study group was subdivided into four groups according to cranial ultrasonographic findings at 2 weeks postnatal age: group A (n = 15) had isolated periventricular/intraventricular haemorrhage; group B (n = 20) had periventricular/intraventricular haemorrhage and dilated ventricles; group C (n = 24) had periventricular/intraventricular haemorrhage and periventricular leukomalacia with or without dilated ventricles; and group D (n = 11) had isolated periventricular leukomalacia. Eighty seven preterm infants with no evidence of intracranial disease and good neurodevelopmental outcomes at 2 years formed the control group. A poor outcome was observed in infants in group B, C, and D, particularly in those who had persistent dilated ventricles at 6 weeks postnatal age and extensive periventricular leukomalacia. There was no difference in outcome between group A and controls. During the first six weeks of life ventricular area growth velocities were significantly higher in groups B, C, D, compared with normal controls and group A. We suggest that persistent ventricular dilatation at this early stage carries a bad prognosis, which is the result of atrophy of the brain. | 4 |
Gemistocytic astrocytomas: a reappraisal. Although gemistocytic astrocytomas are considered slow-growing astrocytomas, they often behave aggressively. To clarify the biological and clinical behavior of these rare tumors, the authors retrospectively identified 59 patients with gemistocytic astrocytoma whose tumors were diagnosed and treated between June, 1976, and July, 1989. Three patients who were lost to follow-up review were excluded, as were two whose original slides could not be obtained and three whose tumors were diagnosed at recurrence or at autopsy. The pathological material of the remaining 51 patients was reviewed using two sets of histological criteria. Thirteen patients (Group A) had "pure" gemistocytic astrocytoma, defined as a glial tumor with more than 60% gemistocytes/high-power field and a background of fibrillary astrocytes. Fifteen patients (Group B) had "mixed" gemistocytic astrocytoma, defined as a glial tumor with 20% to 60% gemistocytes/high-power field and a background of anaplastic astrocytes. Twenty-three tumors did not meet these criteria and were excluded from analysis. The median age of the patients was 48.5 years in Group A and 38.3 years in Group B (p less than 0.05). In both groups, the median Karnofsky Performance Scale score was greater than 90%. All patients underwent surgical procedures (four total and 19 partial resections, and five biopsies) and postoperative radiation therapy. The majority also had interstitial brachytherapy, chemotherapy, or both. Ten patients had one reoperation for tumor recurrence and one had two reoperations; other treatments for recurrence included brachytherapy, chemotherapy, and repeat irradiation. All four patients who originally underwent gross total resection are still alive; all five who had a biopsy have died. There was no significant difference in median survival times between groups: 136.5 weeks in Group A (range 10 to 310+ weeks) and 135.6 weeks in Group B (range 31 to 460+ weeks). Analysis of all 28 patients showed a better prognosis for patients less than 50 years of age (185 vs. 36 weeks survival time; p less than 0.001), patients with preoperative symptoms lasting for more than 6 months (228.1 vs. 110.2 weeks survival time; p less than 0.05), and patients with seizures as the first symptom (185.7 vs. 80 weeks survival time; p less than 0.01). Survival time did not correlate with the presence of perivascular lymphocytic infiltration. The authors conclude that the presence of at least 20% gemistocytes in a glial neoplasm is a poor prognostic sign, irrespective of the pathological background. It is proposed that gemistocytic astrocytomas be classified with anaplastic astrocytomas and treated accordingly. | 0 |
Septal ventricular pacing in the immature canine heart: a new perspective. Cardiac pacing initiated from epicardial or transvenous apical right ventricular electrodes causes asynchronous ventricular contraction. This alters myocardial stress vectors and results in adverse cellular and subcellular changes in the experimental animal. Clinically, such changes may contribute to the adverse hemodynamics reported with long-term ventricular pacing. To determine the feasibility of direct stimulation of the ventricular specialized conduction systems and therefore the potential for maintenance of normalized depolarization patterns, 13 beagle puppies were studied. Baseline ventricular activation and contraction patterns were obtained using intracardiac electrograms and multigated nuclear acquisition (MUGA) imaging. Septal electrode insertion from the aortoatrial groove was accomplished by use of two-dimensional echocardiography and continuous electrocardiographic (ECG) monitoring of the surface ECG during pacemaker implantation in five puppies. Standard right ventricular epicardial electrodes were implanted in five additional animals, with three remaining as age-matched non-paced controls. After 4 months of observation, repeat MUGA imaging and intracardiac electrograms demonstrated nearly normal biventricular activation and contraction patterns among the septal-paced group. Histopathologic examination illustrated normal cellular morphology in the septal-paced animals. This study demonstrates that pacing electrode insertion into the proximal interventricular septum is feasible and results in utilization of the normal ventricular conduction pathway. Such an approach to initiation of ventricular stimulation may attenuate the adverse effects of long-term ventricular pacing. | 3 |
T cell receptor peptide therapy triggers autoregulation of experimental encephalomyelitis. Encephalitogenic T cells specific for myelin basic protein share common V beta 8 peptide sequences in their T cell receptor (TCR) that can induce autoregulatory T cells and antibodies that prevent clinical signs of experimental autoimmune encephalomyelitis (EAE). It is not known, however, if TCR peptides can treat established disease. To test its therapeutic value, TCR-V beta 8-39-59 peptide was injected into rats with clinical signs of EAE. This treatment reduced disease severity and speeded recovery, apparently by boosting anti-V beta 8 T cells and antibodies raised naturally in response to encephalitogenic V beta 8+ T cells. These results demonstrate that synthetic TCR peptides can be used therapeutically, and implicate the TCR-V beta 8-39-59 sequence as a natural idiotope involved in EAE recovery. Similarly, human TCR peptides may be effective in enhancing natural regulation of autoreactive T cells that share common V genes. | 2 |
The large striatocapsular infarct. A clinical and pathophysiological entity. We examined 29 patients with strictly subcortical large striatocapsular infarctions. Eight of them had aphasia or neglect. All patients underwent transcranial Doppler ultrasonography or selective carotid angiography, magnetic resonance imaging, and single photon emission tomography for assessment of cerebral blood flow, blood volume, and cerebral perfusion reserve. The signs were compatible with cortical territorial infarctions rather than lacunes. On both magnetic resonance imaging and computed tomographic scans, the lesions corresponded to the territories of the medial and lateral group of the lenticulostriate arteries, Heubner's artery, or the anterior choroidal artery. The infarctions were either due to cerebral embolization into the M1 segment of the middle cerebral artery or due to stenosis at the same site, ie, lesions that acutely and simultaneously occluded the orifices of the lenticulostriate or neighboring arteries. Persistent occlusion of the middle cerebral arteries and a decrease of cortical regional cerebral blood flow were only found in patients with aphasia or neglect. All patients without aphasia or neglect showed a rapid recanalization of the middle cerebral artery occlusion or a stenosis of the M1 segment and no cortical regional cerebral blood flow decrease. Large striatocapsular infarctions occur due to occlusive disease of the middle cerebral artery (large-vessel disease) and not due to a disseminated in situ occlusion of the long penetrating arteries (small-vessel disease), as in lacunes. Neuropsychological deficits can be explained by decreased cortical blood flow due to a persistent occlusive lesion of the middle cerebral artery. | 2 |
The Van Nes tibial rotationplasty. A functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur. Twelve patients who had a malignant tumor of the distal end of the femur were treated with a Van Nes tibial rotationplasty. The survival rates were comparable with those for above-the-knee amputees and patients who had an endoprosthetic replacement. The results of functional testing showed that these patients performed as well as those who had endoprosthetic replacement and better than those who had above-the-knee amputation. Rotationplasty is therefore a favorable alternative to amputation or endoprosthetic replacement, either as a primary or as a salvage procedure. | 0 |
Hypertrophic smooth muscle in the partially obstructed opossum esophagus. The model: histological and ultrastructural observations. Obstruction is a complication of many esophageal diseases, but the morphological changes occurring in the obstructed esophagus are poorly understood. We developed a model of esophageal obstruction in the American opossum, Didelphis virginiana. A nonconstricting band around the gastroesophageal junction led to esophageal distention and tortuosity in the weeks following its placement. Despite a marked increase of the esophageal circumference, the esophageal wall was not thinned, and the circular muscle layer had actually increased its thickness. This was due to an increase in the size of individual smooth muscle cells with proportional increases in the cell surface area and volume. The electron density of hypertrophic smooth muscle cells varied much more than that of normal esophageal smooth muscle cells. As cell size increased, the tissue became more compact and the size of the extracellular space decreased. Also, the extracellular space was filled by an amorphous electron-dense material. Additional changes in the structure of hypertrophic smooth muscle cells included prominent intermediate filaments in the vicinity of thick filaments. There was no difference in the structure of the hypertrophic smooth muscle at 4 weeks and at 8 weeks after placement of the band. The morphological features described here resemble those seen in human esophageal spasm and achalasia of humans and could affect esophageal smooth muscle function. | 4 |
Intravenous nicardipine: an effective new agent for the treatment of severe hypertension. Fifty-six patients with severe hypertension were treated with intravenous nicardipine for infusion periods of eight to twenty-four hours. Each patient achieved satisfactory blood pressure control during the infusion period with a mean controlling dose of 7.85 mg/hr. The dose of nicardipine needed for sustained blood pressure control correlated with untreated diastolic blood pressure but not with untreated systolic blood pressure. These results demonstrate the potential usefulness of intravenous nicardipine for the treatment of severe hypertension requiring rapid lowering, and they suggest also that the severity of pretreatment diastolic hypertension might be a useful indicator of the dose required for blood pressure control. | 3 |
Evaluation of argon laser surgery in children under 13 years of age. Argon laser surgery is an effective treatment for ectasias and congenital port-wine stains; however, its use in children under the age of 13 is controversial. This paper reviews 202 children under the age of 13 who underwent argon laser treatments for congenital port-wine stains, spider angiomas, epidermal nevi, and lentigines. The clinical characteristics of port-wine stains in 170 children are discussed. Good to excellent results (moderate to complete clearing) in port-wine stains were obtained in 60 percent of patients and seemed to correlate best with lack of blanchability on pressure. Hypertrophic scarring was seen in only 7 children, all of whom had undressed wounds; no significant scarring has been seen in any subsequent child who had maintained a dressed wound postoperatively. | 3 |
The influence of hyperglycemia and diabetes mellitus on immediate and 3-month morbidity and mortality after acute stroke. Fasting serum glucose, glycosylated hemoglobin, and fructosamine concentrations were determined in 304 consecutive subjects admitted with acute stroke, within 48 hours of ictus. Based on the medical history and these results, subjects were divided into known diabetics, newly diagnosed diabetics, subjects with stress hyperglycemia, and nondiabetics. The type of stroke was classified as lacunar infarct, cerebral infarct, or intracerebral hemorrhage, based on clinical examination by a neurologist and computed tomographic brain scan and/or autopsy. Immediate and 3-month outcomes were examined in relation to (1) fasting glucose, glycosylated hemoglobin, and fructosamine levels by stroke subtypes, and (2) glucose tolerance categories by stroke subtypes. A high fasting glucose level was associated with an increased mortality, but this was observed only among patients with intracerebral hemorrhage. Patients with stress hyperglycemia, but not diabetics, had increased mortality. In spite of having similar glucose concentrations to those patients with stress hyperglycemia, diabetics did not have a worse outcome compared with nondiabetics. It is concluded that the association between glucose concentration and outcome is a reflection of stress relating to stroke severity, rather than a direct harmful effect of glucose on damaged neurons. | 4 |
Acute pain relief. Pain is a multidimensional psychophysiologic phenomenon. Systematic multidimensional assessment is an essential first component of an effective plan to relieve the pain. Nurses are key to effective pain management because of the close, 24-hour-a-day relationship with the hospitalized patient. It is the nurse who is most critical to the adequate assessment of pain, to the implementation of the treatment plan, and to the evaluation of efficacy. Nurses should continue to develop a better knowledge base about pain and pain therapies and assessment skills, be assertive in obtaining effective treatment for their patients, and perceive themselves as responsible for pain relief. | 2 |
Suddenly symptomatic brain tumors at altitude. High-altitude cerebral edema can present with a wide variety of neurologic manifestations; these symptoms resolve with descent. The persistence of neurologic symptoms after descent suggests an intracranial lesion. Brain tumors suddenly becoming symptomatic at altitude have not been reported previously. We report three cases of previously unsuspected brain tumors that suddenly became symptomatic at high altitudes. | 0 |
Sinistral (left-sided) portal hypertension. Between 1953 and 1988, 21 patients with splenic vein thrombosis (SVT), 12 of whom had sinistral portal hypertension (SPH) were treated at our institution. SVT was identified at autopsy in nine patients. Twelve additional patients presented with SPH: bleeding esophageal varices, SVT and normal hepatic function. SVT was caused by pancreatic neoplasm (5), chronic pancreatitis (5), and pancreatic pseudocyst (2). SVT was diagnosed by splanchnic angiography, splenoportography, computerized tomography, and ultrasonography. Gastric varices were diagnosed by endoscopy (10) and barium swallow (2). Splenectomy was performed as primary therapy in 10 patients. Three of these 10 had en block distal pancreatectomy. Two high-risk patients had splenic artery embolization, one as a prelude to splenectomy performed 48 hours later and the other as definitive therapy. One splenectomized patient continued to bleed. No further bleeding occurred in 10 splenectomized patients in follow-up from 1 week to 14 years. Sinistral portal hypertension is a clinical syndrome of splenic vein thrombosis caused by pancreatic pathology and manifests as bleeding gastric varices in patients with a patent portal vein and normal hepatic function. Splanchnic arteriography is necessary for accurate diagnosis. Splenectomy is the effective treatment of choice. | 1 |
Locally recurrent parathyroid neoplasms as a cause for recurrent and persistent primary hyperparathyroidism. Between 1982 and 1989, 145 patients underwent operations for persistent or recurrent primary hyperparathyroidism (HPT). At re-exploration, 15 patients (10.3%) were found to have locally recurrent parathyroid tumors (11 patients with adenoma and 4 with carcinoma). These 15 patients had 28 previous operations at outside institutions for HPT. Patients with locally recurrent HPT secondary to adenoma had a longer disease-free interval than patients with locally recurrent carcinoma. At the time of evaluation at the National Institutes of Health (NIH) for recurrent or persistent HPT, each patient was symptomatic and patients with carcinoma had significantly more symptoms and higher serum levels of calcium and parathyroid hormone than patients with adenoma. Locally recurrent parathyroid neoplasm was correctly localized by preoperative testing in 14 of 15 patients. These 15 patients underwent 18 reoperations at NIH for excision of locally recurrent parathyroid tumors. Following the final reoperation (two patients had more than one procedure), each patient had normal serum levels of calcium. In addition each patient remains biochemically cured (based on normal serum calcium level), with a median follow-up interval of 21 months. Local recurrence of parathyroid adenoma comprises a small but significant proportion of cases of recurrent or persistent HPT and can be indistinguishable from parathyroid carcinoma. Findings suggestive of carcinoma include shorter disease-free interval, higher serum levels of calcium and parathyroid hormone, and histologic appearance. Whether the locally recurrent parathyroid neoplasm is benign or malignant, aggressive surgery can control serum levels of calcium in these patients with acceptable rates of morbidity. | 4 |
Percutaneous fine-needle aspiration cytologic study of main pancreatic duct stenosis under pancreatographic guidance. When pancreatography shows a stenosis of the main pancreatic duct in patients with normal or inconclusive ultrasound and computed tomography, the exact nature of such stenosis is sometimes difficult to precise before surgical exploration. In such cases, the authors systematically performed a percutaneous fine-needle aspiration cytologic study of the stenosis under pancreatographic guidance. Fifteen patients were referred because of suspected pancreatic malignancy. The tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 were normal in 11 patients and elevated in one patient, whereas only CA 19-9 was elevated in three others. In 14 cases, both the ultrasound and computed tomography did not show any obvious pancreatic mass. The pancreatography was done through endoscopic retrograde cholangiopancreatography (ERCP) (12 patients) or percutaneously in case of failure at ERCP3 and showed a main pancreatic duct stenosis that underwent aspiration by percutaneous fine needle precisely positioned using biplane fluoroscopy. The aspirated material was then smeared on glass slides, air-dried, and stained by Giemsa. In nine of the 15 patients, cytologic study revealed adenocarcinoma. This was confirmed by surgery in five and by progressive deterioration followed by death in four. In six patients, cytologic study gave a nonmalignant result. Chronic pancreatitis was found in five of them, confirmed at surgery in three and based on uneventful follow-up of at least 12 months in two others. In one case, a pancreatic adenocarcinoma not detected by cytologic study was found at surgery. Thus, the sensitivity and specificity of this diagnostic approach were 90% and 100%, respectively. No serious complication was noticed. The authors conclude that when ultrasound and computed tomography are inconclusive, percutaneous fine-needle aspiration cytologic study of main pancreatic duct stenosis under pancreatographic guidance is a safe, simple, and helpful procedure in the investigation of patients with suspected pancreatic malignancy. | 1 |
Identification of the rate-dependent functional refractory period of the atrioventricular node in simulated atrial fibrillation. We continuously observed successive pairs of R-R intervals during atrial fibrillation and hypothesized that the shortest R-R interval for a given preceding R-R interval in a pair represents the functional refractory period of the atrioventricular node at that preceding interval. To test this hypothesis we simulated atrial fibrillation in 28 isolated cross-perfused canine hearts and obtained an R-R interval scatterplot by plotting the R-R intervals as a function of the immediately preceding R-R interval. This scatterplot enabled us to detect a series of the shortest R-R intervals for a wide range of preceding R-R intervals, and this allowed us to estimate the rate-dependent functional refractory period of the atrioventricular node in simulated atrial fibrillation. The estimated functional refractory periods correlated well with those measured by the conventional method (r = 0.93). We conclude that the proposed method makes it possible to estimate the rate-dependent functional refractory periods of the atrioventricular node in atrial fibrillation. | 3 |
Pupillary and electroretinographic abnormalities in a family with neuronal intranuclear hyaline inclusion disease. Abnormal pupillary function and a severely depressed electroretinogram were found in four members of a family with neuronal intranuclear hyaline inclusion disease, an idiopathic degenerative disorder that involves the central and peripheral nervous systems. Symptoms were limited to the gastrointestinal system and consisted principally of abdominal pain, constipation, and severe weight loss. The discovery of light-fixed pupils in the propositus led to the first antemortem diagnosis by rectal biopsy in two generations of this family. Abnormalities of gastrointestinal motility and pupillary reactions constituted the only objective evidence of autonomic dysfunction; the abnormal electroretinogram was the only evidence of central nervous system dysfunction. | 2 |
Neoadjuvant chemotherapy in invasive bladder cancer: the evolving role of surgery. The role of an operation in patients receiving neoadjuvant chemotherapy for clinically localized but invasive transitional cell carcinoma of the bladder currently is evolving. An operation is essential for case selection and evaluation of local response but it also contributes to bladder preservation and survival. The procedure that is necessary to select for and assess response to chemotherapy may itself alter the actual or proceed to evolution of invasive bladder cancer. Neoadjuvant chemotherapy is a reasonable therapeutic strategy in selected patients but it remains to be seen whether the results will prove to be superior to those achieved with standard endoscopic and open operations. | 0 |
Liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome. We report the case of a young woman with Budd-Chiari syndrome in whom mesentericoval shunt was first performed, followed by transcaval liver resection and hepatoatrial anatomosis 3 years later. Liver transplantation became necessary 5 years later because of deterioarating liver function with portal hypertension and bleeding. Successful transplantation was performed with atrioatrial anastomosis with help of cardiopulmonary bypass, simplifying considerably the technical procedure and reducing dramatically blood loss. | 3 |
Effect of marked peripheral leukocytosis on the leukocyte count in ascites. Patients with high peripheral leukocyte counts are sometimes found to have high leukocyte counts in ascitic fluid in the presence of negative cultures. To determine if peripheral leukocytosis (greater than or equal to 20 x 10(9)/L) by itself can result in high leukocyte or neutrophil counts in ascites, 29 patients were studied. A total of 31 paracenteses were performed in these patients as soon as the high peripheral leukocyte count was determined. Culture of ascitic fluid was performed using blood-culture bottles. The mean peripheral leukocyte count was 29.3 +/- 9.3 x 10(9)/L, with a mean neutrophil count of 19.9 +/- 6.5 x 10(9)/L. The mean ascitic fluid neutrophil count was 0.064 +/- 0.054 x 10(9)/L (range, 0.007 to 0.197 x 10(9)/L). No significant correlation was found between peripheral neutrophil (or leukocyte) count and neutrophil (or leukocyte) count in ascitic fluid. Marked peripheral leukocytosis (or neutrophilia) does not seem to have an effect on the leukocyte or neutrophil count in ascitic fluid. | 1 |
Anterior acromioplasty for treatment of the shoulder impingement syndrome. Between 1975 and 1979, anterior acromioplasty was performed in 65 patients with 66 involved shoulders. The procedure appears to be safe and reasonably effective. Of the 65 patients in this study, 50 had chronic tendon inflammation with fibrosis, and 16 also had a small supraspinatus tendon tear. These 16 had rotator cuff repairs. Twenty-six patients were also treated with distal clavicle excision, and seven had tenodesis of the long head of the biceps brachii. The average age of the patients was 50 years (range, 23-75 years). All patients were followed for an average of eight years (range, three to 13 years). At final evaluation, no or slight pain was present in 77% of the shoulders: 39 of 50 without tendon tearing and 12 of 16 with tendon tearing and repair. Active shoulder abduction averaged 167 degrees. Ninety-two percent returned to employment, including 18% with some job modification. Eighty-six percent returned to recreational athletics, 20% with some modification of activities. Seven patients had additional surgical treatment. The progression of rotator cuff disease is not always prevented, but the need for subsequent shoulder treatment generally decreases. | 2 |
Reoperation for colorectal carcinoma. In the management of the patient with intra-abdominal recurrence of colorectal carcinoma, surgery remains the primary mode of therapy when cure or significant palliation is anticipated. Appreciation of the importance of close follow-up after primary resection coupled with improved diagnostic modalities has allowed the surgeon not only to detect earlier recurrence but also to select the patients most likely to benefit from resection of recurrent disease. Improved surgical techniques with resultant decreases in the rates of morbidity and mortality have allowed safe hepatic resection of metastatic disease. In selected patients, this procedure produces 5-year survival rates approaching 50%. Although a clear consensus has not been reached, most studies agree that positive prognostic indicators include absence of extrahepatic disease, a small number of intrahepatic lesions, a low CEA level, and a better Dukes stage of the primary. Likewise, in the patient with recurrent disease locally, surgery provides the only means of cure and also plays a significant role in palliation. Aggressive resection with generous surgical margins in patients with contained disease may yield 5-year survival rates approaching 35%. In patients with unresectable disease and even in those with carcinomatosis, palliation can be obtained by surgical therapy. Judgment is necessary in treating these patients both preoperatively and intraoperatively. Surgical intervention for obstruction, perforation, or other anatomic or physiological compromise is often indicated and can improve the quality of life of the patient with intra-abdominal recurrence. | 0 |
Herpes simplex virus type 2 meningitis without genital lesions: an immunoblot study. Two sexually active female patients presented with acute meningitis. The CSF abnormalities were severe and persistent. In spite of the absence of genital lesions, serological studies revealed a primary infection by herpes simplex virus type 2. An immunoblot study revealed intrathecal synthesis of anti-herpes antibodies early in the course of the disease. | 2 |
Angiotensin I-forming angiotensinogenases in extrarenal vasculature and in the kidney. The intention of this study was to characterize angiotensin I-forming angiotensinogenases (AIFAs) in rat extrarenal arterial walls and to clarify whether these enzymes are also present in the kidney. A further aim was to identify AIFAs in human vasculature and to establish whether they are affected in essential hypertension. Sprague-Dawley rats and vascular sections of patients undergoing corrective surgery were studied. Enzyme kinetic assays were performed using angiotensin I radioimmunoassay and purified natural angiotensinogens. Fast protein liquid chromatography was employed for biochemical characterization. A series of AIFAs with various isoelectric points, molecular weights and pH optima was detected in rat extrarenal vascular and, with differing distributions of enzyme activities, in renal tissues. In extrarenal arteries the main form of renal renin was present with a relatively low activity only. AIFAs were also demonstrable in human extrarenal vasculature and behaved like plasma renin in essential hypertension. The results indicate the existence of an intrinsic human vascular RAS in extrarenal (and renal) arteries. Extrarenal arterial AIFAs are not generally stimulated in essential hypertensives, as previously postulated. | 3 |
The nuclear pacemaker: is renewed interest warranted? From 1973 through 1987, 155 radioisotope-powered "nuclear" pacemakers were implanted in 132 patients at the Newark Beth Israel Medical Center. The longevity of the first 15 devices, all of which were fixed-rate (VOO) pacemakers, was significantly better than that of 15 lithium-chemistry demand (VVI) pacemakers used as control devices (p = 0.0002). Of the entire cohort of 155 nuclear pacemakers, 136 were VVI devices and 19 were VOO units. The patients with VOO pacemakers needed reoperations more often than did those with VVI pacemakers, chiefly for mode change (p less than 0.001). Power-source failure was observed in only 1 case, but 47 nuclear pacemakers were removed for other reasons, including component malfunction (15 units), mode change (12 units), high pacing thresholds (8 units) and lead or connector problems (5 units). The actuarial survival at 15 years was 99% for power sources and 82% for the entire pacing systems (pulse generators plus leads). The frequency of malignancy was similar to that of the population at large and primary tumor sites were randomly distributed. Deaths most commonly were due to cardiac causes (68%). Thus, nuclear pacemakers are safe and reliable and their greater initial cost appears to be offset by their longevity and the resulting decrease in the frequency of reoperations. It is reasonable to suggest that further use be made of long-lasting nuclear power sources for modern pacemakers and other implantable rhythm-management devices. | 4 |
Physiology of aging related to outcome in the adult respiratory distress syndrome. Thirty-nine patients with adult respiratory distress syndrome (ARDS) were enrolled in a study to identify potential age-related changes in organ system function that may help explain the apparent association between age and poor outcome in these patients. Criteria for enrollment included an arterial PO2-to-inspired O2 concentration ratio less than or equal to 200 in a clinical setting consistent with ARDS. Patients were excluded if they were less than 18 yr old, had clinical manifestations of congestive heart failure, were seropositive for the human immunodeficiency virus, or had stage II metastatic lung cancer. Patients were divided into two groups: those less than 60 yr old (mean 42 +/- 3 yr, n = 17) and those greater than or equal to 60 yr old (73 +/- 2 yr, n = 16). A group of six patients was analyzed as a separate subset based on a body temperature less than or equal to 97.5 degrees F at enrollment (hypothermic patients, 73 +/- 4 yr old). Sepsis was present in 67% of the nonhypothermic patients and in all the hypothermic patients. Mortality rates were 12% in the patients less than 60 yr and 69% in the nonhypothermic patients greater than or equal to 60 yr. All the hypothermic patients died. Sequential data obtained over 6 days were compared within and between groups. The following results were obtained. 1) The ratio of arterial PO2 to inspired O2 fraction was greater and the positive end-expiratory pressure used was significantly less in the patients greater than or equal to 60 yr old compared with the younger group. | 4 |
Characteristics of participants at baseline in the Treatment of Mild Hypertension Study (TOMHS). The Treatment of Mild Hypertension Study (TOMHS) is a randomized, double-blind clinical trial currently being conducted to compare the effects of nonpharmacologic therapy alone with those of 1 of 5 active drug regimens combined with nonpharmacologic therapy, for long-term management of patients with mild hypertension. Six classes of drugs were studied: (1) acebutolol (beta blocker), (2) amlodipine (calcium antagonist), (3) chlorthalidone (diuretic), (4) doxazosin (alpha 1 antagonist), (5) enalapril (angiotensin-converting enzyme inhibitor) and (6) placebo. All participants received nutritional-hygienic advice to reduce weight and sodium and alcohol intakes and to increase physical activity. End points include blood pressure change, side effects and quality-of-life indices; incidence of electrocardiographic and echocardiographic abnormalities; and incidence of cardiovascular clinical events, including death, among participants receiving drugs as first-step treatment as well as nonpharmacologic treatment compared with incidence among those participants randomized to nonpharmacologic treatment only as the initial step. | 3 |
Celiac disease, brain atrophy, and dementia. We report 5 patients who developed dementia before age 60 and were subsequently found to have celiac disease (CD). Intellectual deterioration ranged from moderate to severe, and diffuse cerebral or cerebellar atrophy was found on brain CT. Diagnosis of CD was confirmed by findings of subtotal villous atrophy in jejunal biopsy specimens and positive serum reticulin and gliadin antibodies. Conspicuously, gastrointestinal symptoms were mild. The gluten-free diet failed to improve the neurologic disability except in 1 patient. CD is a multisystem disorder and may play a role in some cases of presenile dementia. Although the pathogenetic mechanisms are obscure, immunologic mechanisms are implicated. | 2 |
Gynecologic cancer in patients with subacute cerebellar degeneration predicted by anti-Purkinje cell antibodies and limited in metastatic volume. Between 1982 and 1989, 19 patients with gynecologic carcinoma, paraneoplastic cerebellar degeneration, and seropositivity for anti-Purkinje cell cytoplasmic antibodies were identified at our institution. Seven of the patients had no clinical, computed tomographic, or magnetic resonance imaging evidence of cancer but had undergone laparotomy solely because anti-Purkinje cell antibodies were found in their serum; all had high-grade adenocarcinoma. Cerebellar symptoms preceded or coincided with the initial cancer diagnosis in 15 patients and preceded the diagnosis of recurrent cancer in 4 patients. The cancers were 14 ovarian, 2 fallopian tube, 2 surface papillary, and 1 poorly differentiated metastatic adenocarcinoma in a periaortic lymph node. Two remarkable surgical observations in patients with high-grade ovarian and tubal cancers were the conspicuous lack of peritoneal implants and the small metastatic volume. A comparison of the 8 patients who had primary stage III cancer with 24 matched control patients without paraneoplastic cerebellar degeneration revealed no difference in primary tumor volume but a significantly smaller volume of metastatic tumor in the seropositive group (P = 0.05). Anti-Purkinje cell antibodies were not detected in 111 neurologically normal patients with advanced ovarian cancer. The small metastatic volume in the face of high-grade and advanced stage malignancy in seropositive patients with paraneoplastic cerebellar degeneration suggests that an immune response to the tumor (presumably cross-reactive with cerebellar cells) may impair the metastatic process. Earlier diagnosis and treatment of cancer, based on prompt serologic testing, may offer an improved neurologic and oncologic prognosis. | 0 |
Hepatic portal venous gas: an unusual presentation of Crohn's disease. Hepatic portal venous gas is associated with numerous conditions and traditionally has been regarded as an ominous prognostic sign. There are several reports of hepatic portal venous gas occurring in patients with inflammatory bowel disease after or during the performance of colonic diagnostic studies. We report an unusual case of Crohn's disease whose initial presentation included hepatic portal venous gas. The literature of hepatic portal venous gas associated with inflammatory bowel disease is reviewed. | 3 |
Endometriosis. An important condition in clinical gastroenterology. Endometriosis, a condition defined by the presence of ectopic endometrium, is a disorder of increasing incidence and a significant cause of gastroenterologic distress in young women. Although clinical manifestations vary considerably depending upon the anatomic extent of disease, characteristic abdominal complaints and typical physical findings continue to be associated with misdiagnosis and delayed recognition of gastrointestinal involvement. The authors of this paper review the medical literature concerning endometriosis of the digestive tract--emphasizing modes of presentation, risk factors, diagnostic testing, complications, and therapy. Greater familiarity with the disease and heightened awareness of its sequellae are needed and prerequisite to improved medical management. | 1 |
Delayed anterior decompression in patients with spinal cord and cauda equina injuries of the thoracolumbar spine. Forty-nine patients with complete and incomplete injuries of the spinal cord or cauda equina who had undergone anterior decompression at a minimum of 3 months after injury were examined. Follow-up was from 12 months to 19 years. Postoperative neurologic improvement occurred in 46.5% of patients with incomplete injuries. If the surgery was performed less than 2 years after injury, neurologic improvement occurred in 68% with an improvement in Frankel grade of 32%. Bladder function improved in 27% of patients and if operated on less than 2 years after injury improvement occurred in 43%. Conus medullaris decompression resulted in a 50% improvement. There was an 83% improvement in the pattern of pain after decompression. Of 23 patients with preoperative spasticity, 10 improved but 6 were worse after surgery. | 2 |
Restenosis after balloon angioplasty. A practical proliferative model in porcine coronary arteries. A model of proliferative human restenosis was developed in domestic pigs by using deep injury to the coronary arterial media. Metal wire coils were delivered percutaneously to the coronary arteries of 11 pigs with an oversized, high-pressure (14 atm) balloon and were left in place for times ranging from 28 to 70 days. During placement, the balloon expanded the coils and delivered them securely within the arterial lumen. Light microscopic examination of the vessels confirmed fracture of the internal elastic lamina by the coil. An extensive proliferative response occurred in 10 of the 11 pigs and was associated with a luminal area narrowing of at least 50% in all but one pig. The histopathologic features of the proliferative response were identical to those observed in human cases of restenosis after angioplasty. Immunohistochemical studies confirmed the prominence of smooth muscle cells in the proliferative tissue. A similar response was obtained in two of five porcine coronary arteries in which balloon inflation only was performed, without coil implant. This model is practical and inexpensive and closely mimics the proliferative portion of human restenosis both grossly and microscopically. Thus, it may be useful for understanding human restenosis and for testing therapies aimed at preventing restenosis after balloon angioplasty or other coronary interventional procedures. | 4 |
Effect of activity on supraventricular tachyarrhythmias after coronary artery bypass surgery. The purpose of this study was to evaluate patient activities, professional staff activities, backrest position, and diurnal variations as factors that may contribute to the onset of supraventricular tachyarrhythmias (SVT) after coronary artery bypass surgery (CABG). The activities surrounding the recognition of first-onset SVT, as well as preoperative and postoperative data and patient characteristics were examined in 249 patients having CABG. One hundred seventy-three patients qualified for the study; 28% of these patients (n = 49) had SVT. No statistical difference was found between the subjects with SVT and those without SVT when sex, cross-clamp time, creatine kinase peak, hemoglobin and hematocrit levels, and number of bypasses were examined. Patients who had SVT were older than those who did not: 64.8 years for the SVT group versus 60.7 years for the non-SVT group (p less than 0.01). SVT was rare in the first 24 hours after surgery, whereas 60% of the cases occurred during the next 48 hours, without significant diurnal variation: mean time of onset was 11:50 AM. No particular activity of the patient or nurse influenced the onset of SVT during the postoperative period in this group. | 3 |
Pleural anesthetics given through an epidural catheter secured inside a chest tube. Pain management after thoracic surgical procedures is a difficult clinical problem. A variety of pain management methods are used with variable efficacy. This paper presents an effective method of pleural anesthetic administration using a pleural catheter inserted through a chest tube. | 4 |
Modern pharmacotherapy of migraine. Rectal ergotamine and naproxen are the major candidates for the ad hoc treatment of migraine attacks; for particularly dramatic episodes, intravenous DHE with prochlorperazine is the author's preference. For long-term stabilization, after simpler measures fail, valproate appears to be a major addition to migraine therapy. | 2 |
Endocrine and renal effects of nifedipine gastrointestinal therapeutic system in patients with essential hypertension. Results of a multicenter trial. The Modern Approach to the Treatment of Hypertension Study Group. Use of thiazide diuretics and beta-blockers in the treatment of hypertension may result in metabolic derangements and/or disturbances in the parameters of renal function, which offset the benefits of blood pressure reduction by adversely affecting other cardiovascular risk factors, particularly in special patient groups such as the elderly or those with concomitant diseases. Newer agents including calcium channel blockers, which exert potent antihypertensive effects without adversely affecting metabolic parameters unfavorably, are used with increasing frequency in hypertensive patients, but their clinical utility has been limited by the need for multiple daily dosing with attendant fluctuations in plasma levels thought to be associated with nuisance side effects and possible gaps in therapeutic protection. The Modern Approach to the Treatment of Hypertension (MATH) trial was conducted to determine the efficacy and safety of the new once-daily nifedipine gastrointestinal therapeutic system (GITS) formulation in a large cohort of mild-to-moderate hypertensive patients overall, and to identify specific effects of therapy in the presence of complicating factors such as diabetes and obesity. A total of 1155 patients from 127 centers were treated with nifedipine GITS in the MATH trial, including 157 diabetic (fasting plasma glucose greater than 120 mg/dL or on hypoglycemic therapy) and 747 nondiabetic patients. There were 458 obese patients (body mass index [BMI] greater than 30), 489 overweight patients (BMI greater than or equal to 25 less than or equal to 30), and 206 patients of normal weight (BMI less than 25). | 3 |
Relationship among level of distraction, evoked potentials, spinal cord ischemia and integrity, and clinical status in animals. Somatosensory evoked potentials (SEPs) and neurogenic-motor evoked potentials (NMEPs) were recorded after overdistraction of the spinal cord at T5-T6, T12-L1, or L3-L4. Measures of spinal cord perfusion and clinical status were also administered. Results indicated that stiffer spinal segments allowed less distraction than more flexible segments. SEPs and NMEPs were lost quickly after overdistraction in stiff segments and slowly in more flexible segments. However, SEPs were less sensitive than NMEPs to effects from overdistraction. Spinal cord perfusion and integrity were consistent with reduced perfusion and structural damage after overdistraction in stiff segments; extremely reduced perfusion but no structural changes in more flexible segments. The application of these results to the clinical situation was provided. | 4 |
Carcinoma of the pancreas: a retrospective review. Eighty-five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment. The most useful diagnostic test was percutaneous transhepatic cholangiography (PTC) with a diagnostic rate of 96%. Pancreaticoduodenectomy (Whipple procedure) and total pancreatic resection were performed in 13 and 2 patients, respectively. The remaining 50 patients underwent various palliative drainage procedures. Twenty patients did not undergo operation for various reasons. The primary tumor was found in the head of the pancreas in 50 patients (59%), the body in 6 patients (7%), and in the tail in 8 patients (9%). Postoperative complications, including sepsis, bleeding, intra-abdominal abscesses, and anastomotic leaks, occurred in 37% of the patients. There were one operative and 9 postoperative deaths. The average survival for those patients undergoing surgical intervention was 6 months. There were no 5-year survivors. | 4 |
Survival in patients with large-bowel cancer. A population-based investigation from the Melbourne Colorectal Cancer Study. Five-year survival data were obtained in 97 percent or 1105 of 1140 new patients with histologically confirmed colorectal adenocarcinoma during a 12-month period in 1981 and 1982, as part of a large comprehensive population-based study of colorectal cancer incidence, etiology, and survival, The Melbourne Colorectal Cancer Study. Fifteen percent of patients were Dukes' A stage, 32 percent were Dukes' B, 25 percent were Dukes' C, and 29 percent were Dukes' D. At five years after diagnosis, the observed survival rate was 36 percent and the adjusted rate was 42 percent. Dukes' staging was a highly discriminating factor in survival (P less than 0.001). Survival rates were better in women than in men and better for patients with colon cancer than for patients with rectal cancer. Survival by Dukes' staging was not affected by colon subsite or by the tumor being the first and single tumor, metachronous tumor, or synchronous tumor. The survival of younger patients was better for Dukes' stages A, B, and C, and worse for Dukes' D. Survival was worse in the presence of bowel perforation in Dukes' C and D stages. Within Dukes' D (incurable cases), survival was best in the absence of hepatic metastases, slightly worse when only hepatic metastases were present, and poorest in the presence of both hepatic and extrahepatic metastases. Statistical modeling of survival determinants other than staging indicated that cell differentiation had the largest effect (survival decreasing with poor cell differentiation), followed by site (survival worse for rectal cancer than colon cancer), then age (survival better for younger patients), while bowel perforation had the smallest effect on survival. | 0 |
Simultaneous bilateral hernia repair. A case against conventional wisdom. The timing of bilateral hernia repair remains controversial. Because of reported high recurrence rates after simultaneous bilateral repair, staged procedures have been suggested. This study determined recurrence and complication rates of unilateral versus simultaneous bilateral repair. Of 659 patients undergoing hernia repair between 1974 and 1980, 333 underwent unilateral repair and 329 had simultaneous bilateral repair. More than 90% of patients were followed until death or a minimum of 60 months (median, 104 months). Perioperative complications were associated with 18% of repairs. More morbidity occurred in the bilateral group. However complication rates for specific events were not significantly different, except for urinary retention, which occurred in 20 patients (6.1%) of the unilateral group and 49 (15%) of the bilateral group (p less than 0.001). Overall 25 recurrences occurred in the unilateral group and 31 in the bilateral group. Recurrence rates at 5 and 9 years were, respectively, 4.8% and 8.8% in the unilateral group and 5.0% and 9.1% in the bilateral group (p = 0.861). These data suggest that simultaneous bilateral inguinal herniorrhaphy does not result in increased rates of most postoperative complications or recurrence when compared with unilateral repair. | 4 |
Femoral arteriovenous fistula as a complication of percutaneous transluminal coronary angioplasty. A report of five cases. Arteriovenous fistula (AVF) associated with invasive and diagnostic angiographic procedures is rare. The incidence is increased with procedures such as percutaneous transluminal coronary angioplasty (PTCA) but is still quite low. We report five cases of AVF within a 17-month period, representing 0.15 per cent of all cardiac catheterizations and 0.87 per cent of PTCAs. All five patients presented with groin bruits. There were two associated pseudoaneurysms and one patient with deep vein thrombosis. All patients underwent uneventful division of the fistula. A thorough understanding of the anatomy of the femoral triangle is necessary in order to avoid this complication. That all fistulas were in the superficial or profunda femoris arteries emphasizes the importance of avoiding a low groin puncture. Early angiography and surgical intervention are recommended for optimal results. | 4 |
Coccidioidomycosis during human immunodeficiency virus infection. A review of 77 patients. Through a retrospective review, we identified 77 previously unreported cases of coccidioidomycosis during HIV infection. Patients were classified into 1 of 6 categories based on their primary clinical presentation: 20 had focal pulmonary disease (Group 1), 31 had diffuse pulmonary disease (Group 2), 4 had cutaneous coccidioidomycosis (Group 3), 9 had meningitis (Group 4), 7 had extrathoracic lymph node or liver involvement (Group 5), and 6 has positive coccidioidal serology without a clinical focus of infection (Group 6). Coccidioidal serologies were positive on initial testing in 83% of the patients in whom such serologic testing was performed. Sera from 39% of patients were positive for TP antibodies while 74% had CF antibodies. Eleven of 12 seronegative patients had pulmonary disease (Group 1 or 2). Serologic results of other patients sent to a single reference laboratory were similar, with 26% positive for immunodiffusion TP antibodies and 79% positive for immunodiffusion CF antibodies. For the 77 patients in this study, the CD4-lymphocyte count was below 0.250 X 10(9) cells/L in 46 of the 55 patients who had this test performed, and a low CD4 count was significantly associated with mortality (p less than 0.01). At the time of follow-up, 32 of the 77 patients (42%) had died. There were significantly more deaths in those with diffuse pulmonary disease (Group 2) than in other groups (p less than 0.001). Amphotericin B, ketoconazole, fluconazole, and itraconazole were all used as antifungal therapies. Outcome could not be related to the therapy used. Of note, 3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions. | 1 |
Effects of menstrual phase and amenorrhea on exercise performance in runners. There are few well controlled studies in terms of subject selection, menstrual classification, and exercise protocol that have examined both maximal and submaximal exercise responses during different phases of the menstrual cycle in eumenorrheic runners and compared these runners to amenorrheic runners. Thus, the purpose of this study was to measure selected physiological and metabolic responses to maximal and submaximal exercise during two phases of the menstrual cycle in eumenorrheic runners and amenorrheic runners. Eight eumenorrheic runners (29.0 +/- 4.2 yr) and eight amenorrheic runners (24.5 +/- 5.7 yr) matched for physical, gynecological, and training characteristics were studied. The eumenorrheic runners performed one maximal and one submaximal (40 min at 80% VO2max) treadmill run during both the early follicular (days 2-4) and midluteal (6-8 d from LH surge) phases. The amenorrheic runners performed one maximal and one submaximal (40 min at 80% VO2max) treadmill run. Cycle phases were documented by urinary luteinizing hormone and progesterone assays and by plasma estradiol and progesterone assays. No differences were observed in oxygen uptake, minute ventilation, heart rate, respiratory exchange ratio, rating of perceived exertion, time to fatigue (maximal), and plasma lactate (following the maximal and submaximal exercise tests) between the follicular and luteal phases in the eumenorrheic runners and the amenorrheic runners. We conclude that neither menstrual phase (follicular vs luteal) nor menstrual status (eumenorrheic vs amenorrheic) alters or limits exercise performance in female athletes. | 4 |
Cardiopulmonary perfusion and cerebral blood flow in bilateral carotid artery disease The fear of cerebral complications after cardiopulmonary bypass in patients with heart disease and severe carotid artery disease has led many authors to suggest combined approaches in these patients. The pathogenetic mechanism for stroke is based partly on the stenotic narrowing of the carotid artery. A diameter reduction of 75% is frequently considered hemodynamically significant and indicative of an increased risk for neurological morbidity. We studied the cerebral blood flow in 7 patients undergoing coronary artery bypass grafting who also had severe bilateral carotid disease. The results were compared with the results in 17 patients without carotid disease who had bypass grafting. The cerebral blood flow was measured by xenon 133 washout technique before, during, and after cardiopulmonary bypass with moderate hypothermia. Acid-base regulation was according to the alpha-stat theory, and blood pressure was kept greater than 50 mm Hg. The cerebral blood flow levels (mL.100g-1.min-1) before, during, and after cardiopulmonary bypass in the study group (30 +/- 11, 31 +/- 8, 47 +/- 20) (mean +/- standard deviation) were almost identical to those in the control group (30 +/- 11, 28 +/- 8, 47 +/- 12). The cerebral blood flow levels for the left and right hemispheres in the group with carotid disease were comparable and within normal ranges. In 2 patients, slight differences were noted between hemispheres, and this finding may indicate an increased risk for ischemia. These patients, however, did not show any signs of postoperative deficit. The flow limitations of critical carotid stenoses do not seem to imply a risk for cerebral hypoperfusion if cardiopulmonary perfusion is performed in a controlled manner. | 2 |
Thrombectomy for late graft limb occlusion: our experience in 182 consecutive cases. Late occlusion of an aortofemoral bypass graft is usually caused by fibrointimal hyperplasia or progressive atherosclerosis. Several surgical approaches have been advocated in order to minimize the operative risk, to correct the impaired inflow and to provide a satisfactory outflow. In the last 16 years, in the Institute of Vascular Surgery and Angiology of the University of Milan, we have operated upon 182 consecutive thrombosed grafts. Inflow was restored by performing a graft limb thrombectomy using a Fogarty balloon catheter and simultaneously employing an endarterectomy ring stripper to dislodge tenaciously adherent fibrinous material and thrombotic plug. As the superficial femoral artery was generally occluded, usually a good outflow was achieved by profundaplasty in 101 cases (55.5%) or direct bypass (interposition graft), to a more distal segment of the profunda femoris artery in 55 cases (30.2%). Concomitant popliteal or tibial revascularization was done in the remaining 26 cases (14.3%) when pre-operative or intra-operative findings suggested an inadequate collateral network through the profunda femoris artery. Early re-occlusion, which occurred in 14 cases (7.6%), generally due to insufficient outflow, was corrected by additional intervention in 7 cases (3.8%), while 7 legs were amputated for extensive atherosclerotic disease. Six patients died giving a mortality rate of 3.3%. This low rate in a high risk population is probably related to our policy of operating under loco-regional anaesthesia. Long term results, with a patency rate of 62.0% at 3 years and 60.2% at 5 years (life table method), prove that this operation is a durable procedure for correction of graft limb thrombosis. | 4 |
Full recovery after a chloroquine suicide attempt. The nonfatal case of a 20 year-old woman who ingested 6 grams of chloroquine in a suicide attempt is reported. After initial ventricular fibrillation, she rapidly developed a pulmonary edema with cardiogenic shock. She was successfully treated with diazepam, epinephrine, dobutamine and mechanical ventilation. Plasma chloroquine levels showed an initial peak of 36 micrograms/mL. The patient was discharged fully recovered after 19 days. The interaction between chloroquine and diazepam is discussed, as is the need for careful management of epinephrine therapy. | 3 |
Effects of nimodipine on infarct size and cerebral acidosis after middle cerebral artery occlusion in the rat. The objective of this study was to determine the effect of nimodipine on infarct development and local brain pH after middle cerebral artery occlusion in the rat. Female Fischer-344 rats were subjected to permanent occlusion of the left middle cerebral artery by electrocoagulation. After 6, 12, or 24 hours, brains were frozen, and infarct size, degree of edema formation, and local brain pH were quantified by standard histology or the umbelliferone technique, respectively. In control rats, cortical infarct size was increased from 29.5 microliters at 6 hours to 72.5 microliters at 24 hours after vessel occlusion. In striatum only, an insignificant increase from 15.2 to 24.7 microliters in infarct volume was observed during this period. Edema increased from 7% to 22% in cortical and from 4% to 39% in the striatal infarct areas during this time. Nimodipine (0.1 mg/kg s.c.), given 45 minutes before and again 8 and 16 hours after middle cerebral artery occlusion, did not alter infarct size at 6 hours but considerably improved outcome at later times. Edema formation was lower at 12 hours in the group treated with the calcium antagonist (p less than 0.05). By contrast, effects on local brain pH were seen as early as 6 hours after the vessel occlusion. Nimodipine greatly reduced the areas exhibiting the lowest pH values beyond pH 6.0 (p less than 0.05). Similar effects by nimodipine on brain pH were observed in the 12-hour series, whereas at 24 hours after middle cerebral artery occlusion, a shift to more alkalotic values was noted with no overt differences between control and drug-treated groups. | 2 |
The clinical significance of fluid collections in acute pancreatitis. Computed tomography (CT) displays fluid collections in patients with acute pancreatitis as well defined intra- or extrapancreatic homogeneous areas with low attenuation numbers. We followed, prospectively, the clinical courses of 128 patients who had CT during an episode of acute pancreatitis, to determine the natural history and clinical significance of any fluid collections that developed. Fluid collections were found in 48 (37%) of the 128 patients with pancreatitis. Thirty-eight developed in the 86 (44%) patients with alcoholic pancreatitis, five in the 33 (15%) with biliary pancreatitis and five in the nine (55%) with other causes of pancreatitis (excluding chronic pancreatitis, trauma, or malignancy). On clinical follow-up of the 48 patients with fluid collections, 21 patients required operation; two died before an operation was done and 25 did not require operation. Operations were done to treat pseudocysts (14), abscess (5), and necrosis (3). One patient had an operation for a pseudocyst and an abscess. All 14 patients requiring operation for pseudocyst had collections greater than 7 cm and 13 of these patients had alcoholic pancreatitis. Of the 25 patients not requiring operation, five were lost to follow-up, and 19 of the 20 who had spontaneous resolution of their fluid collection(s) had collections less than 6 cm in diameter. The eight patients who required operative pancreatic debridement for abscess or necrosis had multiple small fluid collections. In summary, fluid collections were found in one-third of patients with acute pancreatitis and were often associated with the development of local complications. | 1 |
Abdominal aortic aneurysm with perianeurysmal fibrosis: experience from 11 Swedish vascular centers. Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03). | 4 |
One hundred percent oxygen reverses muscle hypoxia in a rat hindlimb model of acute arterial occlusion. Significant morbidity results from extremity ischemia after acute arterial occlusion. Reestablishment of arterial flow is considered to be the ideal treatment, yet substantial tissue loss can occur before this is accomplished. Using a rat hindlimb model we investigated whether the administration of 100% oxygen would decrease tissue hypoxia from acute arterial occlusion. Adult male Sprague-Dawley rats were used, and Po2 recordings were taken from the gastrocnemius muscle by use of an oxygen electrode. Baseline muscle Po2 was recorded, and then the femoral artery was occluded. Repeat recordings were made after 20 minutes of ventilation with room air and after an additional 20 minutes of ventilation with 100% oxygen (N = 10). Control groups consisted of animals undergoing occlusion but continued on room air (N = 3) and animals undergoing sham occlusion but receiving the period of 100% oxygen ventilation (N = 3). Femoral artery occlusion produced a reduction in muscle Po2 from 28.0 +/- 1.4 to 6.1 +/- 2.0 (mean +/- SEM, p less than 0.001). Ventilation with 100% oxygen reversed the tissue hypoxia produced by occlusion (27.3 +/- 2.0, p less than 0.001). The administration of 100% oxygen without femoral artery occlusion resulted in a higher tissue Po2 than the occluded + oxygen group (94 +/- 12 vs 27.3 +/- 2.0, p less than 0.001). Mean arterial blood pressure increased in the experimental group concomitant with the administration of 100% oxygen, but there was no correlation between final blood pressure and final tissue oxygen tension. | 4 |
Long-term remission of chronic hepatitis B after alpha-interferon therapy. OBJECTIVE: To evaluate whether remissions of chronic hepatitis B induced by alpha-interferon therapy are of long duration. DESIGN: Cohort study. SETTING: Clinical Center of the National Institutes of Health, a tertiary referral center. PATIENTS: Sixty-four patients with chronic hepatitis B were treated with alpha-interferon between 1984 and 1986. MAIN OUTCOME MEASURES: Patients were followed with frequent examinations and determinations of serum liver biochemical tests and hepatitis B virus (HBV) markers including hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and HBV DNA using blot hybridization and polymerase chain reaction. RESULTS: Among 64 patients with chronic hepatitis B who were treated with alpha-interferon, 23 (36%) responded to treatment with loss of HBeAg and improvement in serum aminotransferases. All 23 have been followed for 3 to 7 years (mean, 4.3 years). During follow-up, 3 of 23 patients relapsed, with reappearance of HBeAg and abnormal serum aminotransferases, all within 1 year of therapy. The remaining 20 patients continued to have no detectable HBeAg or HBV DNA (using blot hybridization) in serum and to be asymptomatic for liver disease, although 3 had minimal elevations in serum aminotransferases. Thirteen patients (65%) became negative for HBsAg between 0.2 and 6 years (mean, 3 years) after loss of HBeAg. Although no patient had HBV DNA that was detectable by blot hybridization, the 7 patients who remained HBsAg positive all had HBV DNA in serum detected by polymerase chain reaction, but only 2 of 13 HBsAg-negative patients had viral genome using this method. Testing sequential samples indicated that HBV DNA detected by polymerase chain reaction usually disappeared at or around the time that test results for HBsAg became negative. CONCLUSIONS: Remissions in chronic hepatitis B induced by alpha-interferon are of long duration and are followed, in most patients, by the loss of HBsAg and all evidence of residual virus replication. | 4 |
Ultrasound-guided fine-needle aspiration biopsy of neck nodes. The assessment of nodal involvement in patients with squamous cell carcinoma of the head and neck is still a major diagnostic problem. Although the sensitivity of imaging techniques for detection of neck nodes is gradually improving, the specificity for metastases remains low. Cytologic examination could, theoretically, supply additive information. Computed tomographic-and magnetic resonance-guided aspiration techniques have been described, but these were not efficacious and laborious. In 1984, we developed a technique for ultrasound-guided (UG) fine-needle aspiration biopsy (FNAB). This technique is described herein, and the value of UGFNAB is compared with conventional FNAB. All statistical characteristics of UGFNAB appeared to be superior to conventional FNAB (sensitivity, 98% vs 88%; specificity, 95% vs 82%; positive predictive value, 98% vs 93%; negative predictive value, 95% vs 74%; and accuracy, 97% vs 87%). Furthermore, UGFNAB was characterized by less nondiagnostic aspirations. It is concluded that UGFNAB is a reliable technique for differentiation between benign nodes and cervical lymph node metastases and it may, therefore, contribute to a more accurate assessment of the neck in squamous cell carcinoma of the head and neck. | 0 |
Survival after hypertonic saline resuscitation from hemorrhage. There has been recent increased interest in hypertonic saline resuscitation from shock and hemorrhage. This study was performed to evaluate the survival effects of hypertonic saline resuscitation. Fifty male Sprague-Dawley rats of average weight of 325 grams were anesthetized with halothane. Animals were subjected to blood loss of 21 ml/kg over 5 minutes. Intravenous infusion was started 10 minutes after hemorrhage with either lactated Ringer's injection (42 ml/kg) or three per cent NaCl (10.64 ml/kg) chosen randomly. These doses provided equal amounts of sodium. At the end of fluid infusion, blood samples were obtained for electrolyte determination. Rats were observed 3 days for survival. Survival was significantly lower in the three per cent NaCl group compared with the lactated Ringer's group. It is probable that worsened outcome with three per cent NaCl was associated with intracellular dehydration. | 4 |
Prospective observations of 100 high-risk neonates by high-field (1.5 Tesla) magnetic resonance imaging of the central nervous system. II. Lesions associated with hypoxic-ischemic encephalopathy. One hundred neonates determined prospectively to be at risk for neurologic handicap underwent magnetic resonance imaging with a high-field (1.5 T) imager. Thirty-three demonstrated a total of 37 lesions consistent with hypoxic-ischemic encephalopathy, including periventricular leukomalacia (n = 12), basal ganglia hemorrhage (n = 5), multicystic encephalomalacia (n = 5), and focal parenchymal hemorrhage (n = 15). Diagnoses by ultrasonography and computed tomography were compared with those by magnetic resonance imaging in 29 and 17 infants, respectively. Ultrasonography agreed more frequently with magnetic resonance imaging than did computed tomography. Ultrasonography detected 79% of lesions demonstrated by magnetic resonance imaging whereas computed tomography detected only 41%. Periventricular leukomalacia was seen most often in preterm infants, basal ganglia hemorrhage and multicystic encephalomalacia primarily occurred in term infants, and focal parenchymal hemorrhage occurred at all gestational ages. Basal ganglia hemorrhage and multicystic encephalomalacia were strongly associated with histories of perinatal asphyxia, seizures, and early abnormal neurological status. All infants with basal ganglia hemorrhage (5/5) and multicystic encephalomalacia (5/5) and the majority with periventricular leukomalacia (9/12) and focal parenchymal hemorrhages (9/15) had developmental abnormalities at discharge. | 2 |
Radiology of esophagitis: a pattern approach. This article presents a pattern approach for diagnosing esophagitis at double-contrast esophagography. In patients with nodular elevations of the mucosa, discrete plaques should suggest Candida esophagitis, whereas poorly defined nodules should suggest reflux esophagitis and a distinctive reticular pattern of the mucosa should suggest Barrett esophagus, particularly if adjacent to the distal aspect of a high stricture. In patients with ulceration, one or more shallow ulcers at or near the gastroesophageal junction should suggest reflux esophagitis, whereas discrete, superficial ulcers in the midesophagus should suggest herpes or drug-induced esophagitis, depending on the clinical setting. In contrast, one or more giant, relatively flat ulcers should suggest cytomegalovirus esophagitis, particularly in patients with acquired immunodeficiency syndrome. Finally, thickened longitudinal folds may be caused by esophagitis, varices, or, rarely, "varicoid" carcinoma, but these conditions usually can be differentiated on radiologic grounds. By carefully analyzing the appearance and location of nodules, plaques, ulcers, or abnormal folds in the esophagus, one can usually suggest a cause of the disease. | 1 |
Choreoathetosis after deep hypothermia without circulatory arrest In 8 of 758 patients undergoing an intracardiac operation under cardiopulmonary bypass and hypothermia, choreoathetosis developed 3 to 7 days postoperatively. Before the onset of choreoathetosis, varying degrees of neurological dysfunction were noted. Electroencephalography and neuroimaging failed to detect any responsible functional or structural changes. Six patients are alive 1 to 3 years postoperatively, and their condition is improving. Two patients died of aspiration or sepsis. All patients were grouped based on factors identified as being possibly causative: depth of hypothermia, cooling time, flow rate, and repeated hypothermia. The incidence of choreoathetosis was significantly different in group A (rectal temperature greater than 25 degrees C) compared with group B (rectal temperature less than or equal to 25 degrees C) (0/295 versus 8/463; p = 0.02). Based on cooling time, the incidence of choreoathetosis was significantly different in group B1 (cooling time less than 1 hour) compared with group B2 (cooling time greater than or equal to 1 hour) (1/220 versus 7/243; p = 0.05). Based on flow rate during cooling, group B2 was further divided into the low-flow group (less than 1,500 mL.min-1.m-2) and the high-flow group (greater than or equal to 1,500 mL.min-1.m-2). Although not significant, the incidence of choreoathetosis was higher in the high-flow group (6/153 versus 1/90; p = 0.22). In group B patients having reoperation, the incidence of choreoathetosis was higher than in patients operated on for the first time (5/54 versus 3/409; p less than or equal to 0.0001). | 4 |
Progressive degeneration of the right temporal lobe studied with positron emission tomography. A 79 year old man with a twelve year progressive history of prosopagnosia and recent naming difficulty, in whom other intellectual skills were preserved, is described. Positron emission tomography (PET) revealed an area of right temporal lobe hypometabolism, with an additional area of less severe hypometabolism at the left temporal pole. This may represent an example of progressive focal cortical degeneration similar to that associated with primary progressive dysphasia, but affecting the right temporal lobe. | 2 |
Head and neck paragangliomas: a clinicopathologic study with DNA flow cytometric analysis. A total of 11 head and neck paragangliomas were the subject of pathologic study, including histologic, immunohistochemical, and DNA flow cytometric analyses. We cannot absolutely predict aggressive clinical behavior using histologic parameters alone, but we can use such parameters to segregate patients into low-risk and high-risk groups. Several trends were observed in the current study. Tumors with higher S-phase fractions, G2/M fractions, or aneuploid cell populations tended to behave "aggressively." The presence of sustentacular cells in the primary tumors cannot be used as an absolute indicator of tumor metastatic potential, as two metastatic paragangliomas in this study contained sustentacular cells in both the primary and metastatic lesions. DNA ploidy status cannot be used as an absolute prognostic parameter as the two metastatic tumors were composed of diploid primary and metastatic lesions. The three tumors with aneuploid cell populations showed "aggressive" histologic and clinical features, but the length of the follow-up period for these cases is too limited to draw any conclusions. Although no absolute criteria can be used at present to gauge aggressiveness, close follow-up of these patients is essential, especially if pathologic findings suggest an "aggressive" course (ie, "malignant" histology, higher S-phase fractions, G2/M fractions, aneuploid cell populations, or decreased sustentacular cell density). | 0 |
Duodenal-caval fistula. Duodenal-caval fistula is a rare, often lethal disease that requires prompt diagnosis and surgical correction. A case of duodenal-caval fistula due to duodenal ulceration is presented and discussed. | 4 |
Cardiac risk in vascular surgery. The oral dipyridamole-thallium stress test. The value of the oral dipyridamole-thallium stress test in identifying patients at high risk of myocardial infarction after vascular procedures has not been documented. We studied prospectively 46 patients who underwent an oral dipyridamole-thallium stress test before undergoing vascular operations. Twenty patients (43%) had a positive test result, defined by a thallium defect with reperfusion, while 26 patients had a negative test result. Myocardial infarctions were documented postoperatively in 5 (25%) of 20 of the group with positive results and 1 (4%) of 26 of the group with negative results. Three of the six myocardial infarctions were clinical; all three were in the group with positive results. No correlation was identified between dipyridamole-thallium stress test results and clinical cardiac history. A positive dipyridamole-thallium stress test result is a more sensitive predictor of postoperative myocardial infarction than ejection fraction or history of coronary artery disease. The oral dipyridamole-thallium stress test is as useful as the intravenous test in this setting. | 3 |
The use of flumazenil in a neonate. Side effects of benzodiazepines used during pregnancy are described in a neonate. Recurrent apnea was reversed after administration of flumazenil, a specific antagonist of benzodiazepines. | 4 |
Efficacy and morbidity of partial laryngectomy and postoperative radiation therapy. In recent years, we have seen increasing use of partial laryngectomies for larger lesions that were previously treated by total laryngectomy. The resultant closer margins have made postoperative radiation therapy an important adjuvant treatment to conservation laryngeal surgery. We review the University of California, Los Angeles, experience with combination partial laryngectomy and postoperative radiation therapy between 1973 and 1987 for treatment of carcinoma of the larynx. Twenty-four such patients who underwent partial laryngectomies and postoperative radiation therapy are examined. Techniques of treatment, complications, and the functional ability of the remaining larynx are discussed. The locoregional control rate at 5 years was 80%. Risk factors associated with an increased risk of recurrence were positive margins, vascular invasion, and extranodal spread. There were no major problems with postoperative wound healing or airway management during the radiation treatment. Vocal and swallowing function were well preserved in most cases. We conclude that combination partial laryngectomy and radiation therapy permits preservation of laryngeal function without serious complications, and therefore is an effective treatment for selected patients with carcinoma of the larynx. | 0 |
Triggers of transient myocardial ischemia: circadian variation and relation to plaque rupture and coronary thrombosis in stable coronary artery disease. The phenomenon of transient myocardial ischemia is common in patients with stable coronary disease and appears to be due both to increases in myocardial demand and to episodic coronary vasoconstriction. The circadian variation of transient ischemic episodes closely parallels the circadian variation of acute coronary syndromes associated with plaque rupture, such as myocardial infarction and sudden death. These concordant temporal patterns of transient ischemia, myocardial infarction and sudden cardiac death probably represent independent manifestations stemming from the consequences of increased sympathetic activity. | 3 |
CO2-welded venous anastomosis: enhancement of weld strength with heterologous fibrin glue. The milliwatt CO2 laser was used to perform end-to-end anastomoses in canine jugular veins. There was a high disruption rate (50%) in laser-welded veins (n = 10). Fibrin glue (n = 17), formed from human fresh-frozen plasma, enhanced the weld strength decreasing the disruption rate (18%), resulting in an 82% patency which nearly equaled the contralateral sutured vein patency (93%). The bursting strength was improved with fibrin glue. Transmural necrosis was present initially in all groups but extended for a longer distance in the vessel wall in laser-welded anastomoses. Sutured anastomoses exhibited a greater inflammatory response. In laser-welded anastomoses endothelial cells were not as confluent as in sutured anastomoses by six weeks. Carbon dioxide laser-welded end-to-end vein anastomoses appear to be impractical because they disrupt too easily. However, the addition of heterologous fibrin glue to the weld results in a reasonably strong anastomosis with histologic properties that may be beneficial in vein bypass grafts. | 4 |
Propranolol and the morning increase in sudden cardiac death: (the beta-blocker heart attack trial experience). To provide insight into the protective effect of propranolol on mortality after myocardial infarction observed in the beta-Blocker Heart Attack Trial, the time of occurrence of sudden cardiac death was examined in this population. Between 5 A.M. and 11 A.M., 25 of the 56 total deaths (38%) occurred in the placebo patients compared with 11 of 45 (24%) in the propranolol patients. Excluding this period, there were nearly equal numbers of sudden cardiac deaths in the propranolol and placebo groups. This retrospective analysis suggests that beta blockade is protective during the morning hours when a surge of sympathetic activity may increase the risk of sudden cardiac death. | 3 |
Cardiac arrhythmias from a malpositioned Greenfield filter in a traumatic quadriplegic. A case study is presented of premature Greenfield filter discharge with intracardiac migration and resulting life-threatening arrhythmias. These arrhythmias also interfered with the patient's transition from ventilatory support via orotracheal intubation to noninvasive positive airway pressure ventilatory support methods. The patient's arrhythmias were controlled by a demand cardiac pacemaker and cardiac glycoside therapy. No anticoagulants were used. She had no further filter migration nor significant complications for 16 months after hospital discharge. | 2 |
Acute renal failure in obstructive jaundice in cholangiocarcinoma. This study was aimed at defining the natural history of renal failure in obstructive jaundice due to cholangiocarcinoma, which is an important health problem in northeastern Thailand. Sixty-four patients among a total of 130 patients with obstructive jaundice secondary to cholangiocarcinoma who developed acute renal failure were studied retrospectively. Analysis was made with respect to clinical features, laboratory findings, and outcome. The development of renal failure before surgery was observed in all patients. It was nonoliguric in 80% and was associated with severe jaundice, gram-negative infection (42%), hypotension (31%), hypoproteinemia (30%), hyponatremia (56%), and hypokalemia (63%). The mean duration of renal failure was 2 weeks. All patients underwent surgery for the relief of jaundice. Seventy-seven percent of the patients survived and had recovery of renal function after the relief of jaundice. Twenty-three percent of the patients died of infection. Clinical data highlight the higher serum bilirubin levels and the frequent occurrence of hyponatremia, hypokalemia, and hypotension in renal failure. Their possible roles in contributing to the development of renal failure are discussed. | 0 |
Detection of hepatitis B virus DNA by polymerase chain reaction in plasma of volunteer blood donors negative for hepatitis B surface antigen. Plasma samples from 206 volunteer blood donors were tested for hepatitis B virus (HBV) DNA by dot blot hybridization and polymerase chain reaction (PCR). All donors were negative for hepatitis B surface antigen (HBsAg) and had normal serum alanine aminotransferase levels. None of the 206 plasma samples was positive for HBV DNA by dot blot hybridization assay. However, nine samples were positive for HBV DNA by PCR using two primer pairs specific for surface and core regions. Nine persons received the HBV-DNA-positive plasma, and one developed posttransfusion non-A, non-B hepatitis; the others remained well 6 months later. Therefore, approximately 4% of blood donors in Taiwan have low titers of HBV DNA, and a more sensitive method to screen donors may be needed in the future, although the current serologic test remains the most practical at present. | 1 |
Hepatic giant cavernous hemangioma with microangiopathic hemolytic anemia and consumption coagulopathy. We describe a case of hepatic giant cavernous hemangioma with both microangiopathic hemolytic anemia (MAHA) and consumption coagulopathy, but without thrombocytopenia, which was completely cured by surgical resection of the tumor. The patient was a 54-yr-old Japanese woman whose chief complaint was right upper abdominal discomfort. Angiography and dynamic computed tomography revealed typical findings of hepatic cavernous hemangioma. The patient also had hematological disorders. At surgery, we performed an atypical right lobectomy to preserve as much normal liver tissue as possible. The patient has been well, with no related complaints or abnormal laboratory findings, 5 yr since her operation. This case indicates that giant cavernous hemangioma of the liver should be considered in the differential diagnosis of MAHA, and if surgical treatment is adequate, hematological abnormalities may be eliminated. | 3 |
Gonadotroph adenoma of the pituitary mimicking a prolactinoma. In a 41-year-old woman with mild hyperprolactinemia and amenorrhea, preoperative hormonal and neuroradiological findings suggested the diagnosis of a macroprolactinoma. She underwent transsphenoidal surgery since the tumor size had not changed in spite of bromocriptine administration for 5 months. Consequently, this case was diagnosed as a female-type gonadotroph adenoma on the basis of its characteristic ultrastructural features including a honeycomb Golgi complex, even though endocrinological and immunohistochemical findings were not those of a typical gonadotroph adenoma. | 0 |
The effect of diaper type and overclothing on fecal contamination in day-care centers [published erratum appears in JAMA 1991 Jun 5;265(21):2810] Fecal coliform contamination of environmental surfaces and hands in the day-care center is common. This study evaluated the effect of two diaper types on fecal contamination. Ten rooms in four day-care centers containing 141 children were studied in a prospective, randomized, crossover study. A total of 2946 samples were cultured during the 9-week study. Fecal coliforms were isolated from 307 inanimate objects (15%), 73 toy balls (46%), and 131 hands (17%). The number of contaminated inanimate objects was significantly less in rooms where paper diapers were worn when compared with that in rooms where double cloth diapers with plastic overpants were worn and in rooms where clothes were worn over diapers. Inanimate object cultures had more contamination in rooms in which diarrhea had occurred. Containment of feces by overclothes and diaper type may be important in decreasing transmission of enteric pathogens in day-care environments. | 1 |
Aetiology of pancreatic cancer Curative surgery is possible in only a small minority of patients with pancreatic cancer and, to date, responses to chemotherapy and radiotherapy have been disappointing. To make any impact on the incidence of the disease a clearer understanding of its aetiology is required. This review explores present knowledge of the aetiology and epidemiology of pancreatic cancer. | 0 |
Is thioridazine retinopathy progressive? Relationship of pigmentary changes to visual function. Thioridazine toxicity has been described as a 'progressive chorioretinopathy', but this designation can be misleading. During the first year after thioridazine exposure retinal pigmentation evolves from a granular to a patchy or nummular appearance. However, visual function and the electroretinogram typically improve during this period. Some cases may show chorioretinal atrophy and functional loss many years later, but there is little evidence for ongoing drug-related progression. Late atrophy may represent degeneration of cells that were injured subclinically at the time of initial drug exposure. Although thioridazine toxicity produces an evolving pigmentary disturbance, functional changes must be monitored independently of fundus appearance. | 4 |
Is baldness a risk factor for coronary artery disease? A review of the literature. A literature search identified eight articles containing data on both baldness and coronary artery disease (CAD). Three of these articles described case-control studies that showed a positive relationship between baldness and CAD when controlling for CAD risk factors. Three other case-control studies showed no such relationship, but these did not control for CAD risk factors. The results of two cohort studies were inconclusive. Insufficient data were available from these studies to analyze possible relationships between baldness and CAD risk factors themselves. Overall, the data reviewed suggest that a small risk of CAD due to baldness may exist, but this risk is smaller than that of well-known CAD risk factors such as smoking and hypertension. Future research should emphasize proper control for age and CAD risk factors. | 3 |
Surrogate receptor-mediated cellular cytotoxicity against malignant human glioma cells. A method for incorporating palmitate-derivatized antibody molecules into effector cells and the influence of these incorporated antibodies (surrogate receptors) on the lytic potential of peripheral blood lymphocytes is described. This surrogate receptor-mediated cellular cytotoxicity provides a means by which killer cells are directed specifically to the desired target glioma cells. The cytotoxic activity does not require the Fc region of the incorporated antibody molecules and shows more lytic potential than ordinary antibody-dependent cellular cytotoxicity. By complement-mediated cell depletion and Percoll gradient separation, the effector cell populations for surrogate receptor-mediated cellular cytotoxicity are found to be natural killer cells, as in the murine system. This strategy of surrogate receptor incorporation into effector cells may provide not only valuable insights into the mechanism of cell-mediated cytotoxicity, but also a means of generating target-specific effector cells for clinical applications in neurosurgery. | 0 |
Kawasaki disease: echocardiographic features in 91 cases presenting in the United Kingdom. Ninety-one patients with Kawasaki disease were examined by cross sectional echocardiography between 1980 and 1988. In the 75 patients evaluated during the acute phase of the illness (the first month), the first echocardiographic examination was carried out at a mean time of 16 days (range 5-30) and coronary arterial lesions were seen in 21 (28%). Two patients with medium sized aneurysms had myocardial infarctions, and one died. Coronary arterial lesions persisted in 17 (23%) patients, most often in younger children. The remaining 16 patients were examined from one month to four years after their acute illnesses, and this group did not have coronary arterial abnormalities. Seven patients with coronary artery lesions have reached school age and require regular echocardiographic examination and exercise electrocardiography. Selective coronary arteriography may be indicated in some patients to identify coronary artery stenosis, which the Japanese experience has shown may progress for several years after the acute illness. | 3 |
Use of m-[131I]iodobenzylguanidine in the treatment of malignant pheochromocytoma. The efficacy and safety of m-[131I]iodobenzylguanidine ([131I]MIBG) were assessed in 15 patients with malignant pheochromocytomas in a nonrandomized, single arm trial, in which patients were treated with [131I]MIBG (SA, 740 megabequerel/mg) every 3 months. Seven of these patients had bone and soft tissue metastases, 4 had only soft metastases, and 4 had only bone metastases. The follow-up period ranged from 6-54 months; the number of doses ranged from 2-11, with 2.9 (78.4 mCi) to 9.25 gigabequerel (GBq) (250 mCi)/administration and a cumulative activity from 11.1-85.90 GBq (300-2322 mCi). The absorbed cumulative dose in tumors ranged from 12-155 Gy. A beneficial effect of the treatment was observed in 9 patients (60%). No complete remission of the disease was observed. Seven patients died during the study, among whom 4 never responded to the treatment. Seven had hormonal responses (4 complete and 3 partial), with a duration ranging from 5-48 months. Among these patients, 4 relapsed, and 3 died within 3 months. Five patients had partial tumoral responses mainly located in soft tissues and for a duration ranging from 29-54 months. All patients with a hormonal response had objective improvement in clinical status and blood pressure. There was no clear-cut relationship between the cumulative dose and the responses. The main side-effect observed in 1 patient with widespread bone metastases after three doses (12.9 GBq) was a pancytopenia, which resolved after treatment was discontinued. This study suggests that repeated [131I]MIBG treatment could be effective in patients with advanced malignant pheochromocytoma. | 0 |
Clinical and anatomical considerations for nonoperative therapy in tibial disease and the results of angioplasty. For a 6-year period, 96 patients had 146 below-knee angioplasties. There were 31 total occlusions and 95 multiple stenoses. All patients had distal ischemia, and 40% had gangrene. The primary success rate was 97%, and the 2-year limb salvage rate was 83%. The ankle/brachial index increased from a mean of 0.25 before the procedure to 0.62 afterward. At 2 years (35 patients), the mean ankle/brachial index was 0.55. For the same period, 320 femorodistal bypasses were performed. The results of angioplasty are comparable to those of surgery, but angioplasty is only suitable in about 20-30% of patients presenting with isolated tibial disease. Suitable lesions are five or fewer stenoses and occlusions 5 cm or less in length. | 4 |
Complications of percutaneous abdominal fine-needle biopsy. Review. To determine whether the increasing use of percutaneous fine-needle biopsy of abdominal lesions is associated with an increase in serious complications, the author updated a literature search and evaluated a questionnaire (distributed among selected hospitals in the United States in 1986 and 1987) that followed up a questionnaire distributed in 1983. The updated literature review revealed a total of 24 deaths and 20 needle tract seedings. The updated questionnaire revealed five deaths after 16,381 biopsies (0.031%), whereas the previous questionnaire had shown four deaths after 63,108 biopsies (0.006%). Two similar European questionnaires revealed mortality rates of 0.008% and 0.018%, respectively. Of the total of 33 deaths, 21 involved biopsies of liver lesions; six involved pancreatic biopsies. Seventeen of the 21 deaths after liver biopsies were secondary to hemorrhage; five of the six deaths after pancreatic biopsies were due to pancreatitis. Of the 23 instances of needle tract seeding, 10 occurred after biopsies of pancreatic malignancies. The frequencies of needle tract seeding in the four questionnaires were 0.005%, 0.006%, 0.003%, and 0.009%, respectively. Although infrequent, serious complications may be associated with this procedure. The author makes suggestions that may help minimize them. | 4 |
Diagnosis of thymoma in myasthenics using anti-striated muscle antibodies: predictive value and gain in diagnostic certainty. Assay of anti-striated muscle antibodies (StrAb) is used as a diagnostic test for thymoma in individuals with myasthenia gravis. Unfortunately, false positive results are common, and their effect on test accuracy is magnified by the relatively low frequency of thymoma in myasthenics. We estimated the predictive values of positive and negative StrAb assays (PV+ and PV-) and gain in diagnostic certainty using values for sensitivity, specificity, and thymoma frequency previously reported in the literature. Sensitivity for indirect immunofluorescence assays ranged from 0.83 to 0.84 (pooled estimate = 0.84; n = 68). Specificity ranged from 0.73 to 0.88 (pooled estimate = 0.77; n = 898). Frequency of thymoma ranged from 0.07 to 0.17 (pooled estimate = 0.12; n = 4,515). The expected gain in diagnostic certainty from StrAb was minimal in those aged 0 to 20 and those aged 60+. In those aged 20 to 60, a negative test helped to exclude thymoma, and a positive test raised diagnostic suspicion but was not sufficient to establish a diagnosis of thymoma (PV+ = 0.46). | 2 |
Squamous carcinoma metastatic to the sternum. A 63-year-old man had a 10 x 16-cm sternal mass 18 months after a second aortocoronary bypass operation. The resected lesion was a metastatic tumor of squamous histology. No primary tumor was found. The diagnostic work-up and treatment options are presented. | 4 |
Mucin production by human colonic carcinoma cells correlates with their metastatic potential in animal models of colon cancer metastasis. Patients with mucinous colorectal cancers characteristically present with advanced disease, however, the relationship between mucin production by colon cancer cells and their metastatic potential remains unclear. We therefore sought to define the relationship between mucin production by human colon cancer cells and metastatic ability by employing animal models of colon cancer metastasis. LS LiM 6, a colon carcinoma cell line with high liver metastasizing ability during cecal growth in nude mice produced twofold more metabolically labeled intracellular mucin and secreted four- to fivefold more mucin into the culture medium compared to poorly metastatic parental line LS174T. This was accompanied by a similar elevation in poly(A)+ RNA detected by blot hybridization with a human intestinal mucin cDNA probe, and increases in mucin core carbohydrate antigens determined immunohistochemically. Variants of LS174T selected for high (HM 7) or low (LM 12) mucin synthesizing capacity also yielded metastases after cecal growth and colonized the liver after splenic-portal injection in proportion to their ability to produce mucin. Inhibition of mucin glycosylation by the arylglycoside benzyl-alpha-N-acetyl-galactosamine greatly reduced liver colonization after splenic-portal injection of the tumor cells. These data suggest that mucin production by human colon cancer cells correlates with their metastatic potential and affects their ability to colonize the liver in experimental model systems. | 4 |
Absence of estrogen receptors in dysplastic nevi and malignant melanoma. Benign nevi, dysplastic nevi, and primary and metastatic malignant melanomas were evaluated for the presence of sex hormone binding and estrogen receptor protein. We have confirmed the observation of Ellis et al. that some pigmented lesions possess sex hormone-binding proteins. We could not demonstrate a true estrogen receptor in any benign nevi, dysplastic nevi, primary melanomas, or metastatic melanomas. Thus the ability to bind estrogen or progesterone does not correlate with the presence of a true estrogen receptor. Lack of nuclear estrogen receptors suggests that the influence of estrogen on the pathophysiology of melanoma or of benign melanocytic nevi may not be significant. | 0 |
Molecular methods to detect the Philadelphia chromosome. The Ph1 chromosome has two molecular subtypes: a bcr-positive seen in CML and some cases of ALL, and the bcr-negative subtype mainly seen in ALL. In CML, because of the restriction of chromosome 22 breakpoints to the bcr, Southern analysis to detect bcr rearrangements also can be used to detect the Ph1 chromosome. In contrast, the translocation breakpoints on the Ph1 chromosome are scattered in ALL, so that other methods such as PFGE and PCR are necessary to detect the Ph1 chromosome. In both CML and ALL, use of these methods to detect molecular abnormalities may be superior to cytogenetics in detecting chromosomal abnormalities. Southern analysis also can be used in CML to map breakpoint locations within the bcr. This may offer prognostic information as to the length of chronic phase, but there is conflicting information as to the validity of this approach. The modified PCR (using cDNA from mRNA) can be used to detect the Ph1 chromosome and to define which of the molecular subtypes are present. The exquisite sensitivity of this method, which is capable of detecting as little as a single abnormal molecule of RNA or DNA, makes it suited for the detection of minimal residual disease in both CML and ALL. This is particularly useful after intensive therapies, such as bone marrow transplantation. Whether these low levels of fusion gene expression are of prognostic significance is still unclear. | 0 |
Fibrocellular tissue response after percutaneous transluminal coronary angioplasty. An immunocytochemical analysis of the cellular composition. BACKGROUND. Restenosis after initial, successful percutaneous transluminal coronary angioplasty (PTCA) is due to fibrocellular proliferation. METHODS AND RESULTS. The present study focused on the nature of fibrocellular tissue in humans by use of immunocytochemical techniques. Four hearts (five coronary arteries) were investigated; time lapse between PTCA and death varied between 20 days (two arteries) and 1 year 7 months. Proliferating cells stained positive with smooth muscle cell-specific monoclonal antibodies. Cells from early proliferative lesions (20 days) have a phenotypic expression different from cells in "old" lesions. Proliferating cells stained positive with vimentin but were negative with desmin, irrespective of the lesion's age. CONCLUSIONS. The findings indicate a change in actin isoform expression of smooth muscle cells while adapting to a pathological state. | 3 |
Periurethral colonic-type polyp simulating urethral caruncle. A case report. A 50-year-old, black woman presented with a 1-cm, polypoid lesion on the posterior edge of the urethral meatus that had the gross appearance of a urethral caruncle. The histologic features, however, revealed a superficially ulcerated lesion composed of colonic-type mucosal glands with focal regenerative atypia in response to inflammation. A similar histologic pattern is also found in so-called solitary rectal ulcer syndrome and inflammatory cloacogenic polyps arising in the anorectal area. Based upon an English-language literature review, this case appears to be the second reported one of an intestinal-type polyp in this location. The patient had no further problems after excisional biopsy. | 4 |
The associated anomalies that determine prognosis in congenital omphaloceles. Cogenital abdominal wall defects such as omphaloceles can be recognized by fetal ultrasonography. To determine whether associated anatomic features may be useful in determining fetal prognosis, a retrospective study was performed over a 5-year period. There were 28 cases of omphalocele; 16 were larger than 5 cm and classified as giant, and the remainder were considered small. Eleven of the 12 infants with small omphaloceles survived with minimal neonatal complications. Ten of the 16 infants with giant omphaloceles died because of associated congenital anomalies. These were congenital heart disease, central nervous system malformations, and diaphragmatic hernias. This review suggests that the prognosis is good when a prenatal diagnosis of giant omphalocele is made and careful fetal ultrasonography, including echocardiography, does not identify heart, central nervous system, or diaphragmatic malformations, even when there is liver herniation into the omphalocele. | 1 |
Sudden death during empiric amiodarone therapy in symptomatic hypertrophic cardiomyopathy. Amiodarone is reported to improve symptoms and to prevent sudden death in patients with hypertrophic cardiomyopathy (HC). Amiodarone treatment (loading dose 30 g given over 6 weeks; maintenance dose 400 mg/day) was prospectively evaluated in 50 patients with HC in whom the drug was initiated because of symptoms refractory to conventional drug therapy (calcium antagonists and beta blockers). Twenty-one (42%) patients had ventricular tachycardia (VT) during Holter monitoring. Amiodarone significantly and often markedly improved the patients' New York Heart Association functional class status (from 3.3 to 2.7 at 2 months, p less than 0.001) and treadmill exercise duration (p less than 0.001). Eight patients, however, died (7 suddenly) during a mean follow-up period of 2.2 +/- 1.8 years. Of the 7 sudden deaths, 6 occurred within 5 months of initiation of treatment. The 6-month and 1- and 2-year survival rates were 87, 85 and 80%, respectively. The survival rate of patients with VT was significantly worse than that of patients without VT (61 vs 97% at 2 years; p less than 0.01). Sudden death occurred despite abolition of VT on Holter monitoring. Amiodarone increased left ventricular peak filling rate by radionuclide angiography in 20 of 33 patients (61%) (p less than 0.01). Decrease in peak left ventricular filling rate within 10 days of amiodarone therapy (8 of 33 patients) was associated with subsequent sudden death (p less than 0.04). | 3 |
An unusual late complication following surgical repair of tetralogy of Fallot. A case is presented of extrusion of right ventricular outflow tract patch material through a mediastino-cutaneous fistula occurring five years after repair of tetralogy of Fallot. The focus of the mediastinal infection was an infected epicardial pacemaker electrode placed at the time of initial surgery. Subsequent echocardiographic studies showed minimal right ventricular outflow tract or pulmonary arterial dilatation, and, with no further surgery, the child is well after two and a half years follow-up. | 3 |
Nisoldipine--effects on the renin-angiotensin-aldosterone system and catecholamines. Studies in normotensive and hypertensive subjects. We have studied the effects of nisoldipine, a new calcium channel antagonist, on the renin-angiotensin-aldosterone system and on plasma catecholamines in 10 healthy volunteers and in 29 patients with primary essential hypertension. Of these 29 patients, thirteen had normal renin hypertension (NRH), and sixteen had low renin hypertension (LRH). Eight healthy volunteers received placebo. Short-term (24 h) effects were measured in all subjects and long-term (up to 6 months) effects of 10-40 mg nisoldipine daily were monitored in the 29 hypertensive patients. Plasma renin activity (PRA) increased slightly, although this rise was not statistically significant, 1 h after the first dose of nisoldipine in both normotensive subjects and hypertensive patients. After 2 h PRA had returned to the pre-treatment level. No change in PRA was observed after administration of placebo. Plasma angiotensin II (AII) levels showed considerable variation after nisoldipine administration. Plasma aldosterone levels decreased despite the increase in PRA and AII concentrations. However, no concomitant reduction in urinary aldosterone excretion was observed. Plasma noradrenaline levels increased slightly 2-4 h after administration of nisoldipine, and decreased again thereafter, but no changes in plasma adrenaline levels were seen. Nisoldipine had no long-term effects on the renin-angiotensin-aldosterone system or on serum catecholamine levels. | 3 |
Pivotal role of early and sustained infarct vessel patency in patients with acute myocardial infarction. Thrombolytic therapy in acute myocardial infarction unequivocally has improved short- and long-term mortality. The fundamental goal of therapy for evolving myocardial infarction is early and sustained infarct vessel recanalization. The mechanisms linking an open artery with improved long-term survival and other clinical outcomes are presented with use of data from extensive clinical trials. | 4 |
Events following implantation of an intraluminal ringed prosthesis in the ascending, transverse, and descending thoracic aorta. From March 1978 through July 1985, 23 patients underwent implantation of 24 intraluminal ringed prostheses (IRP). There were 18 men and 5 women, with a mean age of 54.7 years, range 15-74 years. Eleven IRP were placed in the ascending aorta, two in the transverse arch, and 11 in the descending aorta. Pathology included acute aortic dissection in four patients, chronic dissection in four, and aortic aneurysm in 16. There were eight hospital deaths (35%). Causes of death included acute cardiac failure in seven patients, and ruptured abdominal aortic aneurysm in one. IRP complications requiring revision included right coronary artery occlusion in three of 11 patients (27%) with an IRP in the ascending aorta. Graft revision was also required in three of 11 IRP implanted in the descending aorta (27%), due to graft occlusion in one and graft stenosis in two. Of the six patients with IRP complications, there were three hospital deaths (50%). All 15 hospital survivors were followed for a mean of 68.5 months, range 5-112 months. There were four late deaths (26.7%). Causes of late death included hemoptysis in one, cardiomyopathy in one, and aortic redissection and rupture in two. We conclude that patients undergoing repair of aortic pathology with IRP have an important risk of early phase events, as technical problems can occur due to malposition and slippage of the securing rings. | 4 |
Total perinatal wastage. A clarification of priorities. The pregnancy outcome of 16,971 women carrying 17,352 living fetuses after 16 weeks gestation was studied. As well as recording perinatal deaths, all losses before 28 weeks and up to one year after delivery were recorded to give a total perinatal wastage rate of 21.6 per 1000 fetuses alive at 16 weeks compared with a perinatal mortality rate (stillbirths plus early neonatal deaths) of 7.8 per 1000 births. All deaths were then classified according to pathological sub-groups. The concept of auditing perinatal care using perinatal mortality was then compared with that using total perinatal wastage. | 4 |
Piezoelectric lithotripsy and soft tissue injury. Safety limits in the experimental and clinical setting. Controversy surrounds the capacity of extracorporeal shock wave lithotripsy to cause soft tissue injury. This study examines the influence of different dosages of shock waves on the gall bladder in both humans and an animal model. Sixty one guinea pigs were divided into groups and subjected to different numbers of shock waves (6,000, 24,000, and 48,000) at different frequencies (2.5, 5.0, 10, 20 shock waves per second) and sacrificed at different intervals. Soft tissue damage after lithotripsy seemed to be related to the number of shock waves administered. In addition, repeated administration of low dose lithotripsy (at weekly intervals for six weeks) did not seem to produce a cumulative injury. Finally, in the animals sacrificed one month after receiving high dose lithotripsy, no soft tissue damage was evident, indicating satisfactory healing. Thirty patients were subjected to either high dose (36,000 shock waves) or low dose (6,000 shock waves) lithotripsy 24 hours before elective cholecystectomy. Both macroscopic and microscopic evidence of soft tissue injury were detected in a significantly higher percentage of patients who received a high dose in a single treatment (p less than 0.05). The group who received repeated low dose lithotripsy showed no evidence of cumulative injury. We conclude that low dose lithotripsy produces minimal soft tissue injury and is safe when repeated up to six times at weekly intervals. | 1 |
Subpleural mononuclear cell infiltration. Significance in the differential diagnosis of pleuritis showing nonspecific histologic findings. To determine if patients who had lymphocyte-rich pleural effusion and a pleural biopsy without any specific findings could be histopathologically differentiated between those with tuberculous and nontuberculous pleuritis, we histologically re-evaluated the pleural biopsies of all patients whose pleural effusion was predominant with lymphocytes and contained no malignant cells. A total of 40 patients with a nonspecific histologic findings of pleural biopsy specimen were categorized based on their ultimate diagnosis as having tuberculous (n = 15), carcinomatous (n = 10) or nontuberculous, benign pleuritis (n = 15). The pleural biopsy specimen of patients with nontuberculous, benign pleuritis frequently showed a band-like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate (10 out of 15 patients), while the same finding was infrequent in those with tuberculous pleuritis (0 out of 15, p = 0.0001) and pleuritis associated with carcinoma (three out of 10, p = 0.082). Based on these results, the presence of band-like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate in pleural biopsy specimens of patients with lymphocyte-rich pleural effusion suggests that the pleuritis is nontuberculous in its nature. | 0 |
Increased survival of patients with massive lymphadenopathy and prostate cancer: evidence of heterogeneous tumour behaviour. The survival of patients with prostate cancer and radiologically detectable lymph node enlargement has been studied prospectively over an 8-year period. Computed tomography in 108 patients presenting with symptoms, signs or biochemical results suggesting lymphatic spread revealed pelvic or abdominal node masses in 60 patients; in 29 (48%), the masses measured more than 4 cm and the maximum node diameter was 15 cm. Two-thirds of patients had advanced (T3/T4) tumour stage. Following treatment, actuarial survival in all 60 patients with nodal enlargement was 40% at 5 years. Within this group, survival in 22 patients with lymphadenopathy but negative bone scans at diagnosis was significantly better than that of 38 patients with both node and bone disease (70% vs 20% at 5 years). This improvement was related both to an apparent inability of certain tumours initially to progress and seed within bone and to a marked sensitivity of the node masses to subsequent hormonal manipulation. Primary tumour grade was proportionally similar in both groups. Unexpectedly, 6 of the 38 patients with combined disease obtained a complete remission after treatment. The reason for this heterogeneous biological behaviour remains unclear; but these observations underscore the importance of vigorous treatment in all patients with advanced lymph node disease. | 0 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.