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Flow cytometric DNA content of adenoid cystic carcinoma of submandibular gland. Correlation of histologic features and prognosis. Flow cytometric analysis of nuclear DNA content was performed in 26 adenoid cystic carcinomas of the submandibular gland using archived, paraffin-embedded tissues. The DNA content was compared with multiple histologic parameters and clinical course. Ten carcinomas (38%) were aneuploid and 16 (62%) diploid. Aneuploid carcinomas demonstrated a higher frequency of solid cytoarchitecture, lymph node metastases, and advanced clinical stage, as compared with diploid carcinomas. Other histologic features predicting aggressive clinical behavior also correlated with abnormal DNA content and included invasion of nerves larger than 0.25 mm and intravascular extension. Our data suggest that DNA content analysis can be an effective objective parameter in the clinicopathologic assessment of adenoid cystic carcinoma. | 4 |
Reversal of chronic hepatic encephalopathy by colonic exclusion: poor correlation with blood GABA levels. Previous studies have suggested that the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) is a key factor in the syndrome of portasystemic encephalopathy. We report the case of a patient with medically intractable portasytemic encephalopathy after portacaval shunt who had marked clinical improvement after creation of an end ileostomy. Plasma GABA and serum ammonia levels were measured before and after ileostomy. Although the clinical syndrome and the EEG improved markedly after the ileostomy, the plasma GABA levels remained markedly elevated. Preoperative and postoperative GABA levels were 865 and 633 pmol/ml, respectively (nl = 100-180 pmol/ml). Our findings confirm previous reports of the efficacy of colonic exclusion in patients with intractable portasystemic encephalopathy. However, our results conflict with the hypothesis that GABA itself is the key mediator of the syndrome. | 4 |
Elapsed time from symptom onset and acute myocardial infarction in a community hospital. STUDY OBJECTIVE: Previous reports have emphasized that thrombolytic therapy for acute myocardial infarction should be initiated within three or four hours of symptom onset to obtain the best clinical outcomes. However, our clinical impression was that late arrivers, who often do not receive thrombolytic therapy, have a good short-term prognosis. Therefore, we investigated the relationships among the elapsed time from symptom onset, thrombolytic therapy, and short-term prognosis in acute myocardial infarction patients. The research hypothesis was that late arrivers have a better in-hospital prognosis because they have less severe disease that may involve spontaneous thrombolysis. DESIGN: Observational cohort study based on reviewing medical records and emergency department service logs. SETTING: 500-bed teaching hospital with medical school affiliation in northeastern Ohio. TYPE OF PARTICIPANTS: Four hundred consecutive patients with acute infarction confirmed by chest pain and positive ECGs or elevated cardiac enzymes. MEASUREMENTS AND MAIN RESULTS: Patients arriving early (elapsed time less than or equal to 1.5 hours) were more likely to be in Killip class III or IV (P = .04) or to have hypotension (P = .0004); and they experienced twofold increased odds of ventricular tachycardia (P = .007), cardiac arrest (P = .03), or death (P = .01). Patients arriving late (elapsed time greater than 3.5 hours) were more likely to have a history of angina (P = .002) and had a better short-term prognosis. CONCLUSIONS: Time of ED arrival after onset of acute myocardial infarction symptoms distinguishes two patient groups that differ in their risk of in-hospital complications. Late arrivers have better short-term prognoses and less (acutely) severe disease, and may have less need for thrombolytic therapy because of possible spontaneous thrombolysis. Patients with prior angina may need education on seeking care if their symptoms change. | 3 |
Pulmonary tolerance of prophylactic aerosolized pentamidine in human immunodeficiency virus-infected patients. The effects of primary and secondary long-term prophylaxis of Pneumocystis carinii pneumonia with aerosolized pentamidine on pulmonary function in HIV+ patients were evaluated. Eighty-one patients, none of whom were drug addicts or had pulmonary Kaposi's sarcoma, were studied. Fifty patients were receiving AP as secondary prophylaxis, 36 monthly and 14 twice-monthly; eight patients with a history of PCP served as control subjects. Twenty-three patients were receiving AP as primary prophylaxis, 12 monthly and 11 twice-monthly. Pulmonary function tests, including spirometry, lung transfer capacity for carbon monoxide (Tlco) and alveolar-arterial oxygen gradient (P[A-a]O2) were evaluated at M1, ie, one month after the diagnosis of PCP, or at the beginning of the AP prophylaxis, and then at three-month intervals (M4 to M13). No differences were observed in the results of spirometry or P(A-a)O2. Among the patients receiving secondary prophylaxis, a significant increase (paired Student's t-test) in Tlco occurred at M7 compared to M1 in the group receiving monthly administrations (p less than 0.01) and in the untreated control group (p less than 0.05); there was no significant difference in Tlco at M13 compared to M1 in the 12 patients who received monthly administrations for this period or at M7 in the 14 patients receiving AP twice-monthly. No significant difference in Tlco was observed at M7 in the primary prophylaxis groups. These results indicate that pulmonary tolerance of AP, as reflected by pulmonary function tests, is good. | 4 |
Hemodynamic and electrophysiologic evaluation of patients with hypertrophic cardiomyopathy surviving cardiac arrest. Hemodynamic and electrophysiologic studies were performed in 30 survivors of sudden cardiac arrest with hypertrophic cardiomyopathy (HC) to determine responsible factors. Electrophysiologic abnormalities alone were present in 27 patients (90%): sinus node dysfunction in 14 (47%), delayed atrio-ventricular nodal conduction in 1 (3%), abnormal His-Purkinje conduction in 7 (23%), an inducible atrial tachycardia in 7 (23%), and inducible sustained ventricular arrhythmia in 21 (70%). Sustained ventricular arrhythmia was polymorphic ventricular tachycardia (VT) in 18 patients (86%), monomorphic VT in 2 patients (7%) and ventricular fibrillation in 1 patient (3%). In 1 patient the arrhythmia recorded during an episode of cardiac arrest and induced at electrophysiologic study was polymorphic VT. VT was induced with less than or equal to 2 extra-stimuli in only 1 patient (3%) but with less than or equal to 3 extra-stimuli in 20 patients (97%). Potential causes of sudden cardiac arrest were found in all patients and were multiple in 13 patients (43%). These were (1) ventricular electrical instability in 21 patients (70%), (2) severe left ventricular outflow tract obstruction in 8 patients (27%), (3) bradycardia in 5 patients (17%), (4) myocardial ischemia associated with hypotension in 5 patients (17%), and (5) atrial tachycardia resulting in hypotension in 4 patients (13%). Of the 21 patients with inducible sustained ventricular arrhythmia, 17 received an implantable defibrillator device and 4 were treated with antiarrhythmic drugs. Seven patients underwent left ventricular septal myectomy. | 3 |
The dynamics of antegrade cardioplegia with simultaneous coronary sinus occlusion. Effects on aortic root infusion pressure, coronary sinus pressure, and myocardial cooling. It has been suggested that antegrade cardioplegia with coronary sinus occlusion improves homogeneous myocardial cooling and reduces myocardial injury in the presence of coronary artery occlusion. Little data are available on the exact relationships among the basic elements or this intervention, including antegrade infusion rate, aortic root pressure, the degree of coronary sinus occlusion, coronary sinus pressure, and myocardial cooling. The purpose of this study was to determine these relationships and to provide some basic guidelines for better understanding of this intervention. Twenty-two sheep were placed on cardiopulmonary bypass, the distal left anterior descending artery was occluded, and the proximal coronary sinus was snared. Sixteen combinations of infusion rate (3, 5, 7, or 9 ml/kg/min) and coronary sinus occlusion (total, subtotal, or moderate occlusion or no occlusion) were adopted for each 2 minutes of antegrade cardioplegia, yielding 96 measurements. Myocardial temperatures in the occluded and nonoccluded regions, aortic root infusion pressure, and coronary sinus pressure were measured during each infusion of cardioplegic solution. Coronary sinus occlusion was then released, and the whole heart was reperfused for 30 minutes for another infusion of cardioplegic solution and measurements. Results showed good degrees of linearity between infusion rate and aortic root infusion pressure for all coronary sinus occlusion and noninfusion groups (p less than 0.01). A positive effect of coronary sinus occlusion on aortic root infusion pressure was observed. The graded increases in infusion rate with various degrees of coronary sinus occlusion were constantly associated with elevation of coronary sinus pressure (p less than 0.01). It was also noted that myocardial temperatures in the region of the occluded left anterior descending artery were significantly lower in coronary sinus occlusion groups than in nonocclusion groups (p less than 0.01 or 0.05). Myocardial temperature in the nonoccluded region decreased significantly with the stepwise increases in infusion rate (p less than 0.01), but not with the increases in coronary sinus occlusion (not significant). Based on this and previous studies, we recommend that the induced coronary sinus pressure be safely maintained in the range of 25 to 35 mm Hg and that further studies be focused on the infusion rate of 5 ml/kg/min with subtotal or total coronary sinus occlusion for the intervention of antegrade cardioplegia plus coronary sinus occlusion. | 3 |
Somatostatin prevents acute pancreatitis after pancreatic duct sphincter hydrostatic balloon dilation in patients with idiopathic recurrent pancreatitis. The purpose of this study was to determine whether prophylactic somatostatin infusion can prevent pancreatitis after hydrostatic balloon dilation of the pancreatic duct sphincter segment in 16 patients with idiopathic recurrent pancreatitis. This study demonstrated that prophylactic administration of somatostatin before, during, and after the procedure diminished the incidence and severity of acute pancreatitis. We recommend consideration of such prophylaxis in patients undergoing this procedure. | 1 |
Brain abscess associated with congenital pulmonary arteriovenous fistula. A case of brain abscess associated with congenital pulmonary arteriovenous fistula was presented and 52 reported cases were reviewed. The brain abscess was successfully treated with repeated aspiration and drainage, and the pulmonary arteriovenous fistula, located in the right lower lobe, was resected. The arteriovenous fistula occurs as a common pulmonary manifestation of hereditary hemorrhagic telangiectasia; however, no symptoms suggesting these two were noted in this case. Brain abscesses can be an initial clinical manifestation in asymptomatic pulmonary arteriovenous fistula. This possible association should be borne in mind in cases of brain abscesses of unexplained etiology. | 4 |
Middle cerebral artery flow velocity waveforms in fetal hypoxaemia. In 81 small-for-gestational age fetuses (SGA) colour flow imaging was used to identify the fetal middle cerebral artery for subsequent pulsed Doppler studies. Impedence to flow (pulsatility index; PI) was significantly lower, and mean blood velocity was significantly higher, than the respective reference ranges with gestation. Fetal blood sampling by cordocentesis was performed in all SGA fetuses and a significant quadratic relation was found between fetal hypoxaemia and the degree of reduction in the PI of FVWs from the fetal middle cerebral artery. Thus, maximum reduction in PI is reached when the fetal PO2 is 2-4 SD below the normal mean for gestation. When the oxygen deficit is greater there is a tendency for the PI to rise, and this presumably reflects the development of brain oedema. | 4 |
Increased ischemic injury but decreased hypoxic injury in hypertrophied rat hearts. The purpose of this study was to compare the degree of ischemic and hypoxic injury in normal versus hypertrophied rat hearts to investigate basic mechanisms responsible for irreversible myocardial ischemic injury. Hearts from rats with bands placed on the aortic arch at 23 days of age (BAND) and sham-operated rats (SHAM, 8 weeks postoperative) were isolated, perfused with Krebs buffer, and had a left ventricular balloon to measure developed pressure. Hearts were made globally ischemic until they developed peak ischemic contracture and were reperfused for 30 minutes. Additional hearts were perfused for 15 minutes with glucose-free hypoxic buffer followed by 20 minutes of oxygenated perfusion. There was an 87% increase in heart weight of BAND compared with SHAM (p less than 0.01). During ischemia, lactate levels increased faster in BAND compared with SHAM, ischemic contracture occurred earlier in BAND than in SHAM despite no difference in ATP levels, and postischemic recovery of left ventricular pressure was less in BAND (26.8 +/- 5.6% of control left ventricular pressure, mean +/- SEM) compared with SHAM (40 +/- 4.6%, p less than 0.05). During hypoxic perfusion, lactate release was greater in BAND than in SHAM (48.8 +/- 1.2 versus 26.6 +/- 0.97 mumols/g, p less than 0.01), and with reoxygenation, lactate dehydrogenase release was less in BAND than in SHAM (13.2 +/- 0.7 versus 19.5 +/- 0.2 IU/g, p less than 0.01). After hypoxia and reoxygenation, left ventricular pressure recovery was greater in BAND than in SHAM (93 +/- 8.4% versus 66 +/- 5.3%, p less than 0.01). Thus, this study suggests that hypertrophied hearts have a greater potential for glycolytic metabolism, resulting in an increased rate of by-product accumulation during ischemia, which may be responsible for the increased susceptibility of hypertrophied hearts to ischemic injury. | 3 |
Clinical management of gastric cancer and concomitant esophagogastric varices. We report the late results of treatment of 13 consecutive patients with gastric cancer and concomitant esophagogastric varices. Of seven good-risk patients classified as Child's class A or B, gastrectomy together with selective shunt operation was performed in two, total gastrectomy with splenectomy in three, and distal partial gastrectomy with paraesophageal devascularization without splenectomy in one. The remaining patient with early gastric cancer underwent distal partial gastrectomy following repeated endoscopic injection sclerotherapy (EIS) for treatment of the esophageal varices. Although the majority of patients who underwent surgical repair of varices (i.e., shunt, splenectomy, or devascularization) died, total gastrectomy with splenectomy was the only procedure that led to control of the esophageal varices. Since partial gastrectomy combined with EIS limits the morbidity and mortality of an extensive resection and at the same time controls esophageal variceal bleeding, it is probably the procedure of choice for patients with a carcinoma in the lower two-thirds of the stomach. Concerning non-surgical cases, two patients were effectively treated using laser endoscopy and EIS, without the occurrence of variceal bleeding. The remaining four patients, given chemotherapy or irradiation for treatment of gastric carcinoma, died within 4 months with variceal bleeding or liver failure. For the poor-risk patients with evidence of severe liver dysfunction, laser treatment and EIS would be the treatment of choice. | 0 |
Bilateral renal cell carcinoma with metastasis to thyroid. A case of bilateral synchronous renal cell carcinomas with metastases to the regional lymph nodes and later to the thyroid gland was treated with aggressive surgical extirpation and adjuvant gamma interferon. The patient continues to have an excellent performance status sixteen months after initial diagnosis despite a large tumor burden at presentation. | 0 |
The surgical treatment of atrial fibrillation. IV. Surgical technique. The operative technique for the current surgical procedure of creating an electrical maze for the treatment of atrial fibrillation is described in a sequential fashion. The accompanying diagrams of the procedure are drawn from the view of the operating surgeon. | 3 |
The renin-angiotensin system and renal function in kidney transplantation. The use of converting enzyme inhibitors (CEI) has permitted us to assess the role of the renin-angiotensin system in the control of arterial pressure and renal function in various conditions. In renal transplant recipients treated by azathioprine and steroids, the occurrence of CEI-induced deterioration of renal function is highly suggestive of renal artery stenosis, whereas renal vasodilatation associated with unchanged glomerular filtration rate in response to CEI is indicative of a significant role of native kidneys. In hypertensive recipients without renal artery stenosis, the absence of renal hemodynamic changes after CEI may be predictive of subsequent chronic rejection. The information provided by CEI is rather different in cyclosporine treated subjects. In this setting, no acute effect of CEI on renal hemodynamics is detectable. Whether the renal response to CEI is similar in cyclosporine when compared to conventionally treated patients with renal artery stenosis remains to be demonstrated. | 3 |
Primary malignant fibrous histiocytoma of the aorta associated with aortic dissection. We report a unique case of primary aortic malignant fibrous histiocytoma presenting clinically as aortic dissection. To our knowledge, this occurrence is the first ever reported. The magnetic resonance imaging technique may provide superiority in the differential diagnosis between tumor and hematoma of aortic dissection. Aortic tumor, although rare, should be included among the causes of aortic dissection. | 3 |
The effect of omental pedicle graft transfer on spinal microcirculation and laminectomy membrane formation. The properties of the omentum and its effect on spinal neurologic disease was investigated. Omental pedicle grafts were transferred to the laminectomized lumbar spines of nine neurologically normal dogs. Grafts were placed on either the dura or the spinal cord. Interruption of the graft's circulation was examined. To study the effect, the artery of the graft was injected with contrast and the graft-dura interface studied histologically. All injected specimens demonstrated vascular connections from the graft to the neural elements. The graft was found to decrease postoperative perineural scarring. The omentum appears to possess properties that could be applied to improve outcomes in spinal surgery. | 2 |
Adrenal medullary implants in the rat spinal cord reduce nociception in a chronic pain model. Previous work in this laboratory has indicated that the transplantation of adrenal medullary tissue into the subarachnoid space of the rat spinal cord can reduce pain sensitivity to acute noxious stimuli, particularly following stimulation by nicotine. This most likely results from the stimulated release of opioid peptides and catecholamines from the transplanted chromaffin cells. However, chronic pain models may more closely resemble human clinical pain, and the arthritic rat model has been used for screening potential therapeutic strategies. The purpose of the present study was to assess the potential for adrenal medullary tissue implanted into the spinal subarachnoid space to alleviate chronic pain. Adrenal medullary tissue was implanted into adjuvant-induced arthritic rats, and changes in body weight and vocalization responses were monitored over the 10 week course of the disease. Results indicate that the severe weight reduction normally associated with this inflammatory arthritis was attenuated by adrenal medullary, but not control, implants. In addition, vocalizations were reduced in animals implanted with adrenal medullary, but not control tissue following nicotine stimulation. This reduction was blocked by the opiate antagonist, naloxone, and partially attenuated by the alpha-adrenergic antagonist, phentolamine. Together, these results suggest that the transplantation of adrenal medullary tissue into the subarachnoid space of the spinal cord may provide a local source of opioid peptides and catecholamines for the reduction of chronic pain. | 4 |
Dynamic CT scanning of pancreatic duct after secretin provocation in pancreas divisum. Variations in pancreatic duct diameter at CT scanning and serum pancreatic amylase response following secretin administration were studied in 29 patients with pancreas divisum and unexplained upper abdominal pain. Eleven healthy individuals were used as controls. At endoscopic retrograde pancreatography (ERP) six patients had signs of marked and six moderate pancreatitis, whereas there were no pancreatitis changes in 17 of the patients. At CT scanning patients with marked pancreatitis (ERP) had significantly increased pancreatic duct diameter as compared to patients without signs of pancreatitis. The duct was visualized in 52% of all patients before and 71% after secretin stimulation the corresponding figures for healthy controls, being 18% both before and after secretin. In patients without signs of pancreatitis, it was demonstrated in 5/17 (29%) before and 11/17 (65%) after secretin, whereas it was seen in 10/12 (83%) pancreatitis patients both before and after the hormonal provocation. In five of the nonpancreatitis patients in whom the duct was measurable before and at all study intervals (10, 20, and 50 min) after secretin, there was a significant duct dilation response both at 10 min and when comparing the maximal duct diameter after secretin to the initial values. In contrast secretin did not affect the duct caliber in pancreatitis patients. Serum pancreatic amylase increased significantly after secretin administration to healthy controls and nonpancreatitis patients but was uninfluenced in the marked and moderate pancreatitis groups, respectively. However, when all pancreatitis patients were grouped together, the amylase levels were significantly elevated by secretin. In conclusion, secretin provocation caused duct dilation at CT scanning in pancreas divisum patients without signs of pancreatitis at ERP. | 1 |
Assessment of middle-ear status during experimental otitis media using magnetic resonance imaging. Magnetic resonance imaging has proved to be a useful tool for in vivo imaging of a variety of tissues. In this study, magnetic resonance imaging was applied to the middle ear of experimental animals with otitis media. Results showed that the presence and distribution of effusion within the middle-ear space could be readily determined. Moreover, following injection of gadolinium-diethylenetriaminepentaacetic acid, a contrast agent, the inflamed middle-ear mucosa could be resolved. A comparison between magnetic resonance imaging and tympanometry with respect to the diagnosis of effusion showed that negative pressure tympanograms were equivocal (50% effusion) and that flat or normal tympanograms were in error in approximately 20% of the observations. These data document a role for magnetic resonance imaging in in vivo studies of the pathogenesis of otitis media with effusion. | 4 |
Methsuximide for intractable childhood seizures. Methsuximide was added to the therapeutic regimens of 25 children with intractable epilepsy. In 15 patients the drug was well tolerated and resulted in a 50% or greater reduction in seizure frequency. No serious or irreversible adverse effects were seen. Methsuximide is frequently overlooked and may be an effective adjunctive antiepileptic for children with intractable seizures. | 2 |
Altered expression of the retinoblastoma gene product in human sarcomas. BACKGROUND. The retinoblastoma-susceptibility (Rb) gene is a prototype tumor-suppressor gene originally isolated from patients with heritable retinoblastoma. This gene encodes a nuclear phosphoprotein whose expression is altered in several types of human tumors. METHODS. We studied the expression of the Rb protein in 44 primary and 12 metastatic high-grade human sarcomas by means of immunohistochemical methods and Western blotting. Computerized image analysis was used to quantify the level of Rb gene product in individual tumor cells. The expression of the Rb gene was then correlated with clinical outcome in the patients with primary tumors. RESULTS. Of the 44 patients with primary sarcomas, 13 (30 percent) had tumors with normal, homogeneous expression of the Rb protein in essentially all tumor cells. Thirty-one patients with primary tumors (70 percent) had altered Rb expression; in 18 (40 percent) the Rb protein was heterogeneously expressed, and in 13 (30 percent) it was detected in fewer than 20 percent of the tumor cells. All 12 of the patients with metastatic sarcomas had altered expression of the Rb protein. When the findings in the patients with primary tumors were correlated with clinical outcome, survival was found to be significantly increased in the patients whose tumors had homogeneous Rb expression, as compared with those with either heterogeneous expression (P = 0.026) or no expression (P = 0.012). CONCLUSIONS. Tumors in which the expression of Rb gene product was decreased were more aggressive than tumors in which this protein was expressed by nearly all cells. The Rb gene product may be an important prognostic variable in patients with these tumors. | 0 |
Thrombotic thrombocytopenic purpura treated with high-dose intravenous gamma globulin. Plasma infusion and/or plasma exchange has become standard therapy in the treatment of thrombotic thrombocytopenic purpura (TTP). The management of patients in whom such primary therapy fails is difficult and uncertain. We have described a patient who obtained a sustained remission with the use of high-dose IV gamma globulin after an initial response to aggressive plasma exchange was followed by prompt relapse. Our case and others suggest that high-dose IV IgG may induce remission in patients with TTP who do not respond to standard plasma infusion and/or exchange. | 4 |
Doppler echocardiographic study of porcine bioprosthetic heart valves in the aortic valve position in patients without evidence of cardiac dysfunction. To study the natural history of the hemodynamic performance of bioprosthetic heart valves, Doppler echocardiograms were recorded in a group of clinically stable patients at 2 and 5 years after replacement of native aortic valves with bioprosthetic valves. Eighteen patients completed a 2-year and 26 patients a 5-year follow-up examination. The effective orifice areas of identical models of bioprosthetic valves (Hancock II) were determined in vitro in a left-sided heart pulse duplicator system. In vivo Doppler-derived effective orifice areas were compared with the in vitro measurements for the same valve size. At both the 2- and 5-year follow-up examinations, the Doppler-derived effective orifice area was significantly less than the in vitro area (p less than 0.0001 at each interval). Ten of 16 valves evaluated serially decreased greater than 0.20 cm2 in the Doppler-derived effective orifice area between studies. The mean decrease in effective orifice area in valves evaluated serially was 0.25 +/- 0.29 cm2 (p less than 0.005). The peak transaortic gradient increased from 21 +/- 6 to 27 +/- 8 mm Hg (p less than 0.01). The mean transaortic gradient increased from 12 +/- 4 to 15 +/- 7 mm Hg (p less than 0.05). It is concluded that serial Doppler echocardiographic studies demonstrate a deterioration in the hemodynamic performance of bioprosthetic valves over time in patients with no symptoms or signs of valvular dysfunction and that Doppler echocardiography may be useful for identifying subclinical bioprosthetic valvular dysfunction. | 3 |
Epidermal nevus syndrome: a neurologic variant with hemimegalencephaly, gyral malformation, mental retardation, seizures, and facial hemihypertrophy. The epidermal nevus syndrome (ENS) is a sporadic neurocutaneous disorder that consists of epidermal nevi and congenital anomalies involving the brain and other systems. From among over 60 patients with ENS presenting with neurologic manifestations, we identified 17 who had hemimegalencephaly based on pathologic or radiologic studies. Associated brain and neurologic abnormalities included gyral malformations in 12 of 12, mental retardation in 13 of 14, seizures in 16 of 17 (including 9 with infantile spasms), and contralateral hemiparesis in 7 of 12. All had ipsilateral epidermal nevi of the head, and several had ipsilateral facial hemihypertrophy. We concluded that these abnormalities comprise a recognizable neurologic variant of ENS that we believe represents the full expression of primary brain involvement. Several patients also had evidence of acquired brain lesions such as infarcts, atrophy, porencephaly, and calcifications, which are best explained by prior ischemia or hemorrhage. Given repeated observations of blood vessel anomalies in ENS patients, we hypothesize that underlying vascular dysplasia predisposes to these acquired lesions. The same cause may be invoked to explain the wide variety of neurologic symptoms reported in ENS patients without hemimegalencephaly. While the cause of ENS remains unknown, several observations suggest a somatic mutation. | 2 |
Dural spinal cord arteriovenous malformation. After multiple hospital admissions and an inpatient rehabilitation stay, a 68-year-old woman was transferred to our rehabilitation facility with a paraparesis of unknown etiology. Previous studies included four CT scans and three MRIs which did not demonstrate the lesion. A myelogram was noncharacteristic. The correct diagnosis, confirmed by selective angiography, was ultimately contingent upon recognition of the clinical features and natural history of dural spinal cord arteriovenous malformations (SCAVM). The unusual combination of this multitude of nondiagnostic imaging studies in the uncommon dural SCAVM served to delay diagnosis and treatment. Such delay may have great functional consequences. This report illustrates the importance of suspecting SCAVM and recognizing its features. Emphasis is placed on the physiatrist's role in assuring proper diagnosis to expedite a timely treatment and to obtain the best functional outcome. A brief review of the classification, clinical features, pathophysiology, diagnosis, and prognosis of SCAVM is presented. | 3 |
Proximal posterior cerebral artery occlusion simulating middle cerebral artery occlusion. We describe 12 cases of acute stroke in which clinical features of proximal posterior cerebral artery occlusion simulated the clinical syndrome of middle cerebral artery occlusion. The majority of patients developed contralateral hemiparesis, homonymous hemianopia, hemispatial neglect, and sensory loss or sensory inattention. All 8 patients with dominant hemisphere lesions were aphasic. Accurate diagnosis in each case was achieved only after a head CT, showing occipital lobe, thalamic, and inferomesial temporal lobe infarction. "Cortical" signs are probably explained by thalamic involvement. Recognition of this syndrome has implications for management and prognosis. | 3 |
The effect of race on the relationship between fetal death and altered fetal growth. This population study examines racial differences in the relationship between birth weight and fetal death. An earlier report showed that a birth weight that results in a fourfold increased risk of stillbirth is not a constant birth weight percentile (2nd percentile at 25 weeks, 17th percentile at 42 weeks). This analysis was applied to 782,430 white and black births in Illinois from 1980 to 1984. Mean and 10th percentile growth for white and black infants is identical before 34 weeks' gestation and growth diverges by 250 gm at term, with white infants being larger. Race-specific birth weights resulting in quadrupling of the stillbirth rate were determined with an exponential regression analysis of the relationship between birth weight and fetal death rate for each gestational age. The data indicate (1) that the birth weights resulting in quadrupling the stillbirth rate are substantially above the Denver 10th percentile and the previously unpublished race-specific Illinois 10th percentiles and (2) that at term white infants demonstrate this constant risk at the 12th percentile, whereas black infants exhibit the risk at the 18th percentile. From these data we conclude that black fetuses are more sensitive than white fetuses to factors that adversely affect growth and that continued use of "race-neutral" data for clinical management in racially heterogenous populations will not accurately predict the risk of stillbirth. | 4 |
Hypertension and diabetes in blacks. This article summarizes the current state of knowledge on the interrelationship between non-insulin-dependent diabetes mellitus, obesity, insulin resistance, and hypertension in our attempt to explore the pathophysiology of the high incidence of diabetes and hypertension in the Black population in the United States. A central role for hyperinsulinemia is proposed, and questions are raised that are suitable for investigative clinical trials. | 3 |
Decision criteria for pure-tone detection used by two age groups of normal-hearing and hearing-impaired listeners. Response criteria from a yes-no task and detection thresholds from two test procedures were measured for four groups of adults: younger normal-hearing, older normal-hearing, younger hearing-impaired, and older hearing-impaired. The two test procedures were an audiological procedure (which does not control for response bias) and a 21FC adaptive procedure (which does control for bias). The signal was a 500 or 4000 Hz tone presented in quiet. All four groups showed an equally conservative response bias in the yes-no task. In addition, neither age nor hearing loss affected the difference (6.5 dB) between the two threshold measures. | 4 |
Hepatitis B vaccination and interleukin 2 receptor expression in chronic renal failure. Only 50 to 60% of dialysis patients develop anti-HBs antibodies following hepatitis B vaccination. The nonresponder state correlates with impaired monocyte function, decreased interleukin-2 (IL-2) production of T cells, and an upregulation of the IL-2 receptor system. In the present study we examined anti-HBs production after hepatitis B vaccination and the in vitro expression of IL-2 receptors in nondialyzed patients with various degrees of chronic renal failure. Forty-four patients with impaired renal function were immunized with 2 micrograms recombinant hepatitis B vaccine and boostered after one and six months. Prior to the first injection IL-2 receptor expression of activated T cells was studied by an in vitro proliferation assay. Sixty-four healthy subjects served as controls. After completion of the third vaccination 55.0% of the patients acquired antibody titers greater than 10 U/liter. The seroconversion rate did not differ between patients with lower (less than 3.5 mg/dl) and higher (greater than 3.5 mg/dl) creatinine levels. In nonresponders IL-2 receptor expression (stimulation index, SI = 10.09 +/- 1.80) was elevated compared to healthy controls (SI = 4.62 +/- 0.35, P less than 0.002) or patients who responded with a high antibody titer (greater than 50 U/liter, SI = 3.12 +/- 0.43, P less than 0.001). Patients who produced low antibody titers (less than 50 U/liter) also presented with enhanced IL-2 receptor expression. These data show that an impaired antibody production following hepatitis B vaccination and an enhanced IL-2 receptor expression of T cells may already be present in early stages of chronic renal failure. | 1 |
Adenovirus 12S E1A gene represses differentiation of F9 teratocarcinoma cells. The F9 teratocarcinoma cell line differentiates in vitro after treatment with retinoic acid and cAMP and has been a widely used model system for the study of the molecular events that are responsible for cellular commitment and differentiation during early development. Previous experiments have suggested intriguing parallels between the control of gene expression during F9 cell differentiation and the regulation of gene expression by adenovirus E1A. Transfection of a 12S E1A-expressing plasmid into terminally differentiated, nonproliferating F9 cells generates, at high frequency, colonies of dividing cells, each of which expresses E1A. Cell lines established from these colonies proliferate in the presence of retinoic acid and have lost the fully differentiated phenotype as characterized by the absence of expression of a series of differentiation-specific genes. We conclude that expression of the viral 12S E1A gene product interferes with retinoic acid-induced F9 cell differentiation. Moreover, the results suggest that the differentiation process, as defined by markers of terminal differentiation, may not be a permanent event but can be reversed by E1A expression. | 0 |
Lymphoma, motor neuron diseases, and amyotrophic lateral sclerosis. We studied 9 patients with motor neuron disease and lymphoma. The following several observations have not been recognized in the past: (1) Motor neuron syndromes are associated with either Hodgkin's disease or non-Hodgkin's lymphoma. (2) The syndromes are not restricted to lower motor neuron disorders; 8 of 9 patients had definite or probable upper motor neuron signs as well, qualifying for the diagnosis of amyotrophic lateral sclerosis. Corticospinal tracts were affected in both postmortem examinations. (3) The combination of motor neuron disease and lymphoma is often accompanied by paraproteinemia (3 of 7 patients studied), increased cerebrospinal fluid protein content (6 of 9 patients), and cerebrospinal fluid oligoclonal bands (3 of 9 patients). (4) In 2 patients, asymptomatic non-Hodgkin's lymphoma was found only because the discovery of paraproteinemia gave impetus to examine the bone marrow. (5) Patients with both upper and lower motor neuron signs (amyotrophic lateral sclerosis) may show physiological evidence of conduction block in peripheral nerves or autopsy abnormalities in peripheral nerves. The cause of this syndrome is not known. Both lymphoma and motor neuron disease could have a common cause, possibly a retroviral infection. The frequency of paraproteinemia suggests that an immunological disorder may play a role in the pathogenesis of the neurological disorder. | 2 |
Computed tomography-guided fine-needle aspiration of retroperitoneal lymph nodes in gynecologic oncology. Computed tomography-guided fine-needle aspiration was performed on 30 retroperitoneal lymph nodes in 29 patients with gynecologic cancer. There were no serious complications. Review of the cytologic material demonstrated malignant cells in 83% of the aspirates. Because the predictive value of a positive aspirate approaches 100%, therapy for metastatic disease can be initiated in these patients with the need for an open biopsy. Among five aspirates in which malignant cells were not seen, the cellularity of the specimen appeared to be the critical factor determining the predictive value of the aspirate. Whereas neither of two patients with negative aspirates of adequate cellularity has developed recurrent disease, two of three patients with hypocellular negative aspirates have. Because a hypocellular negative aspirate from a retroperitoneal lymph node may not be a true reflection of disease status, either repeat aspiration or open biopsy is advisable. | 0 |
Intracranial pressure in African children with cerebral malaria Opening lumbar cerebrospinal fluid (CSF) pressure was measured with a paediatric spinal fluid manometer in 26 of 61 Kenyan children (mean age 39 months) with cerebral malaria. In all cases pressure was above normal (mean [SD]22.6 [7.4] cm CSF, range 10.5-36). Clinical features of our patients suggest that intracranial hypertension is important in the pathogenesis of cerebral malaria in children, especially as a cause of death. We suggest that raised intracranial pressure is secondary to increased cerebral blood volume. Lowering intracranial pressure may significantly reduce the mortality and morbidity of cerebral malaria. The potential risks and benefits of lumbar puncture should be considered carefully in patients with suspected cerebral malaria. | 2 |
Experimental models of temporal lobe epilepsy: new insights from the study of kindling and synaptic reorganization. Temporal lobe epilepsy is a common localization-related epileptic syndrome characterized by complex partial seizures, ictal and interictal epileptic discharges arising from limbic structures of the temporal lobe, and association with hippocampal sclerosis. Temporal lobe epilepsy may follow perinatal injury and febrile convulsions, may be progressive, and frequently becomes refractory to standard antiepileptic therapy. The neurobiology that underlies these features of temporal lobe epilepsy is not known. Recent studies in experimental models have provided new insights that may help clarify the relationship of seizures, hippocampal sclerosis, and temporal lobe epilepsy. Observations from the study of the hippocampus with kainic acid-induced lesions, the kindling model, and other experimental models of epilepsy have demonstrated that seizures induce structural and electrophysiologic alterations in hippocampal pathways that may lead to increased excitability and could play a role in the development and progression of temporal lobe epilepsy. These alterations include mossy fiber synaptic reorganization, induction of NMDA-mediated synaptic transmission, and progressive hippocampal neuronal loss induced by brief kindled seizures. Some of the structural alterations induced by kindling have also been observed in the human epileptic temporal lobe, raising the possibility that mechanisms operative in kindling may play a role in the pathogenesis of hippocampal sclerosis and in the syndrome of human temporal lobe epilepsy. | 4 |
Fludarabine: a new agent with marked cytoreductive activity in untreated chronic lymphocytic leukemia. Thirty-three patients with chronic lymphocytic leukemia (CLL) with advanced Rai stage (III-IV) or progressive Rai stage (0-II) disease were treated with fludarabine as a single agent. Eleven patients (33%) obtained a complete remission (CR), 13 (39%) a clinical CR with residual nodules as the only evidence of disease (nodular partial remission [PR]), and two patients (6%) achieved a PR for a total response rate of 79%. Response was rapid, usually occurring after three to six courses of treatment. The major morbidity was infection. Febrile episodes occurred in 13% of the courses (pneumonia 6%, minor infection 4%, and transient fever of undocumented cause 3%). Fludarabine appears to be the most cytoreductive single agent so far studied in CLL. | 4 |
Induction of mixed erythroid-megakaryocyte colonies and bipotential blast cell colonies by recombinant human erythropoietin in serum-free culture. The effects of recombinant human erythropoietin (rEp) on murine hematopoietic progenitors were studied using a serum-free culture. A high concentration of rEp stimulated the formation of mixed erythroid-megakaryocyte colonies (EM colonies) and blast cell colonies, as well as erythroid colonies, erythroid bursts, and megakaryocyte colonies from normal mouse bone marrow cells. Direct effects of rEp on EM colony, megakaryocyte colony, and erythroid burst formation were confirmed by depletion of accessory cells such as T cells, B cells, and macrophages from crude bone marrow cells, and inhibition of the colonies by the addition of rabbit anti-rEp antibody to the culture in a dose-dependent fashion. Replating experiments were performed to confirm the differentiating ability of blast cell colonies grown in the presence of rEp. Most of the blast cell colonies yielded not only secondary erythroid colonies but also megakaryocyte colonies in the presence of 2 IU/mL rEp. Some of the blast cell colonies produced secondary EM colonies in the presence of 16 IU/ml rEp of 2 IU/mL rEp plus interleukin-3, although no granulocyte-macrophage colonies were found in the secondary culture. These results suggest that Ep acts not only as a late-acting factor that is specific for erythroid progenitors, but also as a bipotential EM-stimulating factor for murine hematopoietic cells. | 4 |
Intracranial pressure and cerebrospinal fluid outflow conductance in healthy subjects. Conductance of cerebrospinal fluid (CSF) outflow (Cout) is an important parameter to be considered in patients with CSF circulation abnormalities. In patients with normal-pressure hydrocephalus it is the single most important parameter in determining if the patient needs CSF shunting. The lower normal limit for Cout has been estimated from the effect of shunting in patients with normal-pressure hydrocephalus, from patients retrospectively reevaluated after recovering from illness, and from patients with known abnormalities in the brain or the CSF system. The true value of Cout in normal individuals, however, has hitherto not been reported. In the present study, Cout has been measured by a lumbar infusion test in eight young volunteers with no suspicion of disease. The mean intracranial pressure (ICP) was 11 mm Hg and a linear relationship was found between CSF absorption and ICP. The mean Cout was 0.11 ml/min/mm Hg and the lower 95% confidence level was 0.10 ml/min/mm Hg. These values are in accordance with those obtained from previous studies. | 2 |
Levels of serum granulocyte colony-stimulating factor in patients with infections. To clarify the physiologic roles of granulocyte colony-stimulating factor (G-CSF) in infectious states in vivo, we examined the serum levels of G-CSF in patients with infection. Serum samples from 24 patients in the acute stage of infection (14 men and 10 women, age 65 to 101, without hematologic disorders), as well as samples from 32 age-matched normal elderly volunteers were investigated. Sixteen of the initial 24 patients were reexamined after the recovery phase. G-CSF levels were examined by quantitative enzyme immunoassay. The G-CSF level in normal elderly controls, 25.3 +/- 19.7 pg/mL, was not different from that reported in other findings. There was no statistically significant relationship between their G-CSF level and peripheral white blood cell count or neutrophilic granulocyte count. The G-CSF level in the acute stage of infection was 731.8 +/- 895.0 pg/mL, with a range of 30 to 3,199 pg/mL. There was no significant difference in G-CSF levels between patients with respiratory tract infection and those with urinary tract infection. In all 16 cases examined, the serum G-CSF level in the acute stage of infection was significantly higher than that after recovery phase, the latter being the same as the level in normal elderly controls. G-CSF must therefore play a significant role in human infectious states in vivo. | 4 |
Nosocomial infections due to Xanthomonas maltophilia (Pseudomonas maltophilia) in patients with cancer. From December 1985 to May 1986, Xanthomonas maltophilia (formerly known as Pseudomonas maltophilia) was isolated at an increased rate at our institution; 52 isolates of X. maltophilia were obtained in cultures of clinical specimens from 38 patients during that time. The records of 35 of these patients form the basis of this study. Twelve (71%) of the 17 infected and nine (50%) of the 18 colonized patients had received or were receiving antimicrobial therapy. Eleven of 17 patients (three of seven with septicemia, three of five with pneumonia, three with urinary tract infection, and two with wound infection) responded to antimicrobial therapy. Microbiologic studies of the potential environmental sources revealed growth of X. maltophilia in two water faucets and in one water sample from the medical intensive care unit. X. maltophilia is emerging as an important nosocomial pathogen in immunocompromised patients, especially those receiving broad-spectrum antimicrobial therapy. | 4 |
Leukoaraiosis, intracerebral hemorrhage, and arterial hypertension. To investigate whether the observed association of leukoaraiosis with intracerebral hemorrhage is direct or mediated by risk factors, we compared 116 patients with intracerebral hemorrhage confirmed by computed tomography and 155 controls without intracerebral hemorrhage, evaluating the prevalence of leukoaraiosis and vascular risk factors. Leukoaraiosis was observed in 21 (18%) of the 116 patients and in 12 (8%) of the 155 controls (p less than 0.01). Only two (6%) of the 31 patients with lobar hemorrhage had leukoaraiosis on computed tomograms, compared with 17 (24%) of the 71 patients with basal ganglionic hemorrhage (p less than 0.05). Leukoaraiosis was significantly correlated with intracerebral hemorrhage after controlling for age and sex by using multiple logistic regression analysis, while the correlation disappeared after controlling for hypertension. Our results indicate that leukoaraiosis is not an independent risk factor for intracerebral hemorrhage. | 4 |
Congenital craniofacial anomalies of ophthalmic importance. Congenital craniofacial abnormalities frequently require ophthalmic evaluation and surgical management. Called upon to perform as part of the craniofacial team managing the often severely deformed craniofacial patient, the ophthalmologist must bring a basic knowledge of craniofacial syndromes and developmental anatomy, as well as clinical acumen to help preserve or improve ocular and adnexal function. As an introduction to this area of ophthalmology, the clinical features, classification, appropriate facial embryology, assessment and surgical considerations of the various congenital craniofacial abnormalities are reviewed. The expanding availability of craniofacial surgeons and surgical teams along with improved surgical results will ultimately require an increasing involvement by many more ophthalmologists in the evaluation and management of these congenital abnormalities. | 4 |
Management decisions in laryngeal carcinoma in situ. Twenty-one patients with laryngeal carcinoma in situ (n = 12) or carcinoma in situ with microinvasion (n = 9) were treated with laser mucosal dissection of the vocal cords and/or superficial laser cordectomy. The normal architecture of the vocal cords was preserved because the depth of vaporization was usually superficial in these early cases. Five patients had recurrence, new tumor, or persistence of abnormal tissue that required additional laser surgical treatments. With a follow-up range of 6 months to 4 years, all patients currently are free of laryngeal abnormality, and no patient has needed open laryngeal surgery or radiation therapy. Transoral endoscopic laser resection of laryngeal carcinoma in situ with or without microinvasion should be the treatment of choice for these early lesions. | 0 |
Norwalk virus genome cloning and characterization. Major epidemic outbreaks of acute gastroenteritis result from infections with Norwalk or Norwalk-like viruses. Virus purified from stool specimens of volunteers experimentally infected with Norwalk virus was used to construct recombinant complementary DNA (cDNA) and derive clones representing most of the viral genome. The specificity of the clones was shown by their hybridization with post- (but not pre-) infection stool samples from volunteers infected with Norwalk virus and with purified Norwalk virus. A correlation was observed between the appearance of hybridization signals in stool samples and clinical symptoms of acute gastroenteritis in volunteers. Hybridization assays between overlapping clones, restriction enzyme analyses, and partial nucleotide sequence information of the clones indicated that Norwalk virus contains a single-stranded RNA genome of positive sense, with a polyadenylated tail at the 3' end and a size of at least 7.5 kilobases. A consensus amino acid sequence motif typical of viral RNA-dependent RNA polymerases was identified in one of the Norwalk virus clones. The availability of Norwalk-specific cDNA and the new sequence information of the viral genome should permit the development of sensitive diagnostic assays and studies of the molecular biology of the virus. | 1 |
Recent trends in cesarean section use in California. Cesarean section use in the United States has increased to 24.7% of deliveries in 1988 and is the most common hospital surgical procedure. California cesarean section rates were examined to measure recent trends in obstetric practices and to project future patterns of cesarean section use. Using discharge abstracts from 1983 to 1987 California hospital deliveries, total cesarean section rates were found to increase from nearly 22% in 1983 to 25% in 1987, an increase of 15%. Using a series of least-squares regression models, time trends in the distribution of indications associated with cesarean section among all deliveries and indication-specific cesarean section rates were evaluated. Increases in the number of women with previous cesarean section and fetal distress contributed to rising cesarean section rates. In addition, indication-specific cesarean section rates increased for breech presentation and dystocia. These trends were counterbalanced, in part, by declining rates of repeat cesarean sections. Trends noted for July 1985 through 1987 did not differ substantially from those observed for January 1983 to June 1985, suggesting that recent policy attempts to alter cesarean section use have not had a measurable effect on existing trends. Projections suggest that California cesarean section rates will rise to a level of 34% by the year 2000. | 4 |
Mucosal characteristics of pelvic ileal pouches. This study aimed to investigate the degree of colonic metaplasia in ileo - anal pouches. Biopsy specimens from 25 patients with functioning pouches, eight of whom had pouchitis, were studied using routine histology, mucosal morphometry, mucin histochemistry, and immunoperoxidase staining with monoclonal antibodies directed towards a 40kD colonic protein and a small bowel specific disaccharidase-sucrase isomaltase. Thirteen patients (including all eight with pouchitis) had subtotal or total villous atrophy and crypt hyperplasia. In this group, nine had colorectal type sulphomucin and the 40kD colonic protein was detected in two. These changes were not observed in patients with less severe villous abnormalities. Sucrase-isomaltase activity was, however, present in all 25 pouch specimens. We conclude that although some ileal pouches acquire certain colonic characteristics, complete colonic metaplasia does not occur. | 1 |
Relative validity of self-reported snoring as a symptom of sleep apnea in a sleep clinic population The purpose of this study was to evaluate the relative validity of responses to three different questions about snoring as indicators for sleep apnea in a population referred to a sleep clinic. Secondary goals were to evaluate the meaning of a "don't know" response to these questions and to examine how the associations between snoring and sleep apnea are influenced by demographics. Results from 1,409 patients in a sleep clinic indicated that nearly all levels of estimated snoring frequency were associated with a greater likelihood of sleep apnea. In addition, a "don't know" response indicated a likelihood of sleep apnea. In the sample from this clinic, sensitivities approximating 90 percent were obtained in men, and specificities approximating 90 percent were obtained in women, but high diagnostic accuracy (high specificity in men; high sensitivity in women) could not be achieved with the three snoring questions used here. Generally, associations between snoring and sleep apnea were independent of age and sex. Single persons, persons living alone, and persons customarily sleeping alone of both sexes all showed associations between self-reported snoring and the presence of sleep apnea. | 4 |
Diagnostic quality and complications of hysterosalpingography: oil- versus water-soluble contrast media--a randomized prospective study. In a prospective randomized study of 417 patients, side effects and complications of contrast media and the diagnostic quality of images obtained after hysterosalpingography (HSG) were evaluated after use of diatrizoate meglumine (104 patients), ioxaglate (105 patients), iohexol (105 patients), or ethiodized poppy-seed oil (103 patients). The authors detected no differences among these groups in the prevalence of pain during HSG. The prevalence of lower abdominal pain and vaginal bleeding after HSG was significantly lower in the group that received ethiodized poppy-seed oil than in the three other groups. The prevalence of pelvic infection or inflammation was significantly lower with ethiodized poppy-seed oil than with water-soluble media. All contrast media provided acceptable diagnostic image quality with regard to fallopian tubes, peritoneal spill, and intraperitoneal distribution. Visualization of the uterine cavity and ampullary rugae was significantly better with water-soluble media than with ethiodized poppy-seed oil, which was associated with a high conception rate and which the authors consider preferable for HSG. | 2 |
Magnetic resonance imaging--the evaluation of choice in residual shunt after congenital heart disease surgery? Accurate anatomic diagnosis presents a dilemma in patients with residual shunt after corrective surgery for congenital heart disease. We describe a patient who, after atrial septal defect repair, developed dyspnea and central cyanosis despite normal pulmonary arterial pressures and right heart chamber size. A role for early MRI is suggested. | 4 |
Glutathione disulfide formation and oxidant stress during acetaminophen-induced hepatotoxicity in mice in vivo: the protective effect of allopurinol. Acetaminophen (500 mg/kg i.p.) induced hepatotoxicity in fasted ICR mice in vivo. Acetaminophen also caused a long-lasting 50% reduction of the hepatic ATP content, an irreversible loss of hepatic xanthine dehydrogenase activity and a transient increase of the xanthine oxidase activity. All effects occurred before parenchymal cell damage, i.e., the release of cellular enzymes. The hepatic content of GSH and GSSG was initially depleted by acetaminophen without affecting the GSSG:GSH ratio (1:200), however, during the recovery phase of the hepatic GSH levels the GSSG content increased faster than GSH, resulting in a GSSG:GSH ratio of 1:18 24 h after acetaminophen administration. The mitochondrial GSSG content increased from 2% in controls to greater than 20% in acetaminophen-treated mice. The extremely elevated tissue GSSG levels were accompanied by a 4-fold increase of the plasma GSSG concentrations but not by an enhanced biliary efflux, although hepatic GSSG formation and biliary excretion were not affected by acetaminophen. Allopurinol protected dose-dependently against acetaminophen-induced cell injury, the loss of ATP and the increase of the GSSG content in the total liver and in the mitochondrial compartment without inhibiting reactive metabolite formation. High, protective as well as low, nonprotective doses of allopurinol almost completely inhibited hepatic xanthine oxidase and dehydrogenase activity, but only high doses prevented the increase of the mitochondrial GSSG content. The data indicate a long-lasting, primarily intracellular oxidant stress during the progression phase of acetaminophen-induced cell necrosis. The protective effect of allopurinol is unlikely to involve the inhibition of reactive oxygen formation by xanthine oxidase but could be the result of its antioxidant property. | 1 |
Treatment of chronic relapsing inflammatory demyelinating polyneuropathy by cyclosporin A and plasma exchange. A case report. A patient with chronic relapsing inflammatory demyelinating polyneuropathy was successfully treated with plasma exchanges and cyclosporin A (CsA). Dynamometric measurements of hand force during the time of CsA treatment showed a highly significant correlation between hand force and CsA blood levels. The largest influence of CsA on hand force occurred 11-13 days after CsA uptake. | 2 |
Definition of the role of contemporary surgical management in cisternal and parenchymatous cysticercosis cerebri. With increasing immigration from endemic regions, the incidence of neurocysticercosis in North America is rising. This retrospective study was undertaken to examine the role of surgery in those cases presenting with large cystic parenchymal and cisternal lesions in the current era of anthelminthic agents administered orally. A total of 237 patients presented with newly diagnosed neurocysticercosis to our institution over a recent 5-year period (mean age, 31.2 years). Among those who presented with cystic mass lesions predominantly affecting the brain parenchyma and cisternal spaces, 20 (8.4%; mean age, 40.2 years) with large cystic lesions subsequently underwent surgical intervention, either because of an emergent presentation or because they were refractory to medical management. Clinical presentation included increased intracranial pressure, focal neurological deficit, and seizure. Radiographic imaging (computed tomography and/or magnetic resonance imaging) demonstrated 12 cases with cisternal lesions, 7 with parenchymal lesions, and 1 involving both compartments. Based on imaging guidelines, 30 operative procedures (excluding shunt revisions) were performed (14 craniotomies, 8 cerebrospinal fluid diversions, 7 stereotactic procedures, and 1 burr hole drainage). Fifteen (75%) showed neurological or symptomatic improvement over a median follow-up period of 36.4 months. There were three surgery-related complications and no deaths. | 2 |
Hyperadrenergic orthostatic intolerance as a result of postpartum blood loss. This article describes a young women in whom orthostatic intolerance developed as a result of protracted postpartum vaginal bleeding. The cardiovascular abnormalities were unresponsive to usual treatment measures, and she required combination therapy directed at increasing plasma volume and decreasing sympathetic nervous system activity. After resolution of her symptoms, the patient required no long-term therapy. Chronic blood loss has not been reported as a cause of this syndrome. | 4 |
Diclofenac-associated hepatotoxicity Diclofenac sodium, a phenylacetic acid-derived nonsteroidal anti-inflammatory drug (NSAID) recently released in the United States, was associated with the development of significant hepatitis in seven patients, with one associated death. Signs and symptoms developed within several weeks of initiation of drug use and generally resolved 4 to 6 weeks following discontinuation of use of the drug. The only patient rechallenged with the drug developed a recurrence of her hepatic abnormalities. In one patient, fatal, fulminant hepatitis developed despite early withdrawal of the drug. Review of the European literature disclosed three additional fatalities associated with diclofenac therapy. It is unclear whether the incidence of hepatotoxicity is higher with this drug compared with other nonsteroidal anti-inflammatory drugs. Careful patient monitoring is advised, and prompt discontinuation of the drug is suggested when signs or symptoms of liver disease develop. | 2 |
Intracranial complications of paranasal sinusitis: a combined institutional review. Intracranial complications of paranasal sinusitis constitute true surgical and medical emergencies. The charts of all patients (n = 649) admitted for acute or chronic sinusitis to the University of Minnesota Hospital and to the University of Michigan Medical Center during a 13-year period (1975 to 1988) were retrospectively reviewed to determine the incidence of complications. The clinical presentation, bacteriology, involved sinuses, influencing host factors, white blood cell count on presentation, length of hospitalization, and postinterventional complications are presented. Twenty-four patients with intracranial complications from paranasal sinusitis are studied for an incidence of 3.7%. Aggressive medical and semi-emergent surgical intervention are required to prevent excessive morbidity and/or mortality. Intracranial complications included subdural empyema, frontal lobe abscesses, intrahemispheric abscesses, cavernous and superior sagittal sinus thrombosis, and osteomyelitis. | 2 |
Preoperative superselective arteriolar embolization: a new approach to enhance resectability of spinal tumors. The extent of surgical resection of spinal tumors is frequently limited by blood loss and technical difficulty associated with the vascularity of the tumors. We report here the use of superselective percutaneous arterial embolization to reduce the rate of blood loss at the time of surgical resection and enhance resectability. The types of tumors treated were metastatic renal carcinoma, metastatic thyroid carcinoma, metastatic melanoma, and giant cell tumor of the sacrum. Two of the patients required repeated embolization and surgery for recurrent symptoms. The estimated blood loss in seven of nine procedures performed on the six patients ranged from 300 to 800 ml, after which no transfusion was required. In two procedures, extensive resection of very large tumors resulted in larger losses of blood, and postoperative transfusion was necessary. No significant complications of embolization or surgery occurred. A key factor in our embolization technique is the use of microfibrillar collagen, which allows occlusion of tumor vessels as small as 20 microns and may prevent reconstitution of the embolized vessels by collateral flow. We conclude that preoperative arterial embolization enhances the resectability of a variety of spinal tumors by reducing intraoperative blood loss. This may provide an additional benefit by reducing the risk related to postoperative transfusion. By permitting a more aggressive surgical approach, the use of preoperative embolization also has the potential to improve outcome in patients with spinal tumors. | 4 |
Misdiagnosis in patients with amyotrophic lateral sclerosis. To confirm our impression that a high percentage of patients with amyotrophic lateral sclerosis are initially misdiagnosed, we reviewed records of 33 patients with a definitive diagnosis of amyotrophic lateral sclerosis seen over 10 years. Fourteen patients (43%) were initially misdiagnosed. Mean time to correct diagnosis was significantly greater for the misdiagnosed group (16.0 +/- 9.3 months) than for the rest of the patients (7.6 +/- 4.1 months). Two of three patients with an initial symptom of dyspnea were misdiagnosed. Three patients underwent laminectomies because of misdiagnosis. Age, stage of disease, and unusual presenting symptoms were not identified as causes of misdiagnosis. Most likely causes were physicians' failure to consider the diagnosis and lack of familiarity with the common clinical presentations of amyotrophic lateral sclerosis. Earlier diagnosis of amyotrophic lateral sclerosis may help prevent medical mismanagement and may benefit patients both medically and psychologically. | 2 |
Sunlight and dysplastic nevus risk. Results of a clinic-based case-control study. The dysplastic nevus (DN) is the most important risk factor and precursor for malignant melanoma. The authors compared the responses of 132 consecutive cases of DN, 186 consecutive cases of cutaneous melanoma, and 239 controls attending the same subspecialty clinic to questions regarding sun sensitivity, sun exposure, and other possible risk factors. Dysplastic nevus cases were younger than controls and were of a higher social class, as indicated by more years of formal education. Sun sensitivity (assessed by reported depth of tan after multiple exposures) was associated with both DN risk and melanoma risk after controlling for age and education in logistic regression analysis (P = 0.009 and 0.03, respectively), but for DN risk this association was nonlinear: the relative risks (versus deep tan) were 2.3 for average tanners, 2.8 for light tanners, and 1.6 for those who reported practically no tan. Sun exposure measures were not associated with DN risk after controlling for age and education, whether or not depth of tan was controlled in the analysis. These observations suggest a role for either sunlight or a trait linked with sun sensitivity in the development of dysplastic nevi. | 0 |
Acute urinary retention in a child with appendiceal abscess: diagnostic dilemma. Rarely do children with appendiceal abscess present with acute urinary retention as the only sign or symptom. This presentation may delay diagnosis and definitive therapy, thereby causing additional morbidity and possible mortality. We report the eighth case of acute urinary retention in a child associated with an appendiceal abscess. | 1 |
A histopathologic study of spinal cord ischemia using an isohistogenic rat upper-half-body transplantation model. To study the histopathologic changes of spinal cords exposed to long-duration complete ischemia, the authors developed an upper-half-body transplantation model of inbred rat. In this model, an infant Lewis rat is transplanted to the inguinal region of another adult Lewis rat using microsurgical vascular anastomosis. Even when 2-week-old donor rats were exposed to complete ischemia for 90 minutes, functions of the spinal cord were comparatively preserved. In histopathologic observations, degeneration proportional to complete ischemia duration was noted. In the 60-minute ischemia group of 2-week-old donor rats, however, no substantial differences from normal spinal cord were observed. Under conditions of equal ischemia duration, it appeared the younger animal had the greater ischemic tolerance. | 3 |
Response of angiographically normal and atherosclerotic left anterior descending coronary arteries to acetylcholine. Acetylcholine-induced constriction of human coronary arteries in vivo is commonly attributed to endothelial dysfunction. To examine the effects of 2 other important determinants of vascular responses--namely, agonist concentration and the segment of circulation under study--the diameters of proximal, middle and distal segments of the left anterior descending artery (LAD) and coronary sinus oxygen saturation were measured in 10 patients with angiographically normal coronary arteries (group 1) and in 7 patients with coronary atherosclerosis (group 2) after intracoronary acetylcholine was infused at concentrations from 10(-7)M to between 10(-4)M and 10(-2)M. In group 1, acetylcholine caused minor (less than or equal to 6%) but progressive dilatation of the LAD up to 10(-4)M, but constriction, particularly of the distal segments and tertiary branches, occurred at higher concentrations. Over the same concentration range, coronary sinus oxygen saturation rose progressively from a basal level of 36 +/- 3% to a maximum of 72 +/- 3% in the absence of changes in heart rate and blood pressure, suggesting marked progressive dilatation of resistance vessels. Concentrations greater than or equal to 10(-3)M caused intense constriction of distal epicardial vessels and, in some cases, anginal pain and objective signs of ischemia. Conversely, in group 2, acetylcholine (infused only up to 10(-4)M for ethical reasons) failed to cause significant changes in LAD diameter. These data suggest that the local acetylcholine concentration and coronary vascular segment under study may determine the observed response to at least an equivalent extent as does the presence or absence of coronary atherosclerosis, raising the question of whether a constrictor response to intracoronary acetylcholine reliably indicates the presence of coronary atherosclerosis. | 3 |
Invasive squamous cell carcinoma of the mandible presenting as a chronic osteomyelitis: report of a case. A case of invasive squamous cell carcinoma of the mandible initially thought to be chronic osteomyelitis is reviewed. Discussion of the origin of the tumor and several imaging techniques used for differentiating maxillofacial infection from neoplasm are discussed. The difficulty of diagnosis of chronic painful maxillofacial lesions illustrates the need for a high degree of suspicion concerning any inflammatory lesion not responding to appropriate therapy. Accurate diagnosis and treatment of such lesions most often necessitates microscopic examination. | 0 |
L-tryptophan associated eosinophilia-myalgia syndrome. Environmental chemicals are increasingly incriminated in the pathogenesis of several disease states. The eosinophilia-myalgia syndrome is a recently described entity attributed to the ingestion of the normal dietary amino acid L-tryptophan. We describe a patient who fulfills criteria for the eosinophilia-myalgia syndrome and who was ingesting supplemental L-tryptophan. Exhaustive investigations failed to reveal other causes for her eosinophilia or her myalgic/neuropathic complaints, and she improved dramatically when she discontinued the L-tryptophan supplements. The mechanisms whereby this chemical may induce this syndrome are discussed. | 4 |
Long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis. Seventy-five primary cemented total hip arthroplasties (THAs) were performed in 53 patients with rheumatoid arthritis and juvenile rheumatoid arthritis. All patients were followed for an average of 7.4 years, unless their prosthetic hips failed before that time. Clinical evaluation was based on a 10-point maximum rating scale, and ratings for pain, walking, function, and activity improved from preoperative values to the most recent follow-up examination. Revision THA was performed for aseptic acetabular loosening in four hips, and femoral loosening in one hip. Sepsis occurred in another four hips. Complications of wound healing occurred in 14 hips. Roentgenographic evidence of loosening was seen in six acetabular components, in three femoral components, and in the femoral and acetabular component of one hip; none of these hips have as yet required revision THA. The Kaplan-Meier survivorship analysis revealed a 93% survival probability at seven years, which fell to 77% at 12 years in these patients. A trend was that younger, larger patients had increased failure and component loosening rates. Cemented primary THA has been a satisfactory operation in the rheumatoid patient. The relatively high rate of wound healing problems and sepsis may be due to the systemic immune nature of rheumatoid arthritis; however, 25% of these prosthetic hips either failed or are at risk for future failure. Thus, improved techniques are still necessary to increase the long-term success of THA in the rheumatoid patient. | 2 |
Role of perfusion pressure and flow in major organ dysfunction after cardiopulmonary bypass. The role of perfusion pressure and flow during cardiopulmonary bypass with moderate hypothermia and hemodilution in the development of new postoperative renal or clinically apparent cerebral dysfunction was examined in 504 adults. Cardiopulmonary bypass flow was targeted at greater than 40 mL.kg-1.min-1 and pressure at greater than 50 mm Hg. Flows and pressures less than target occurred in 21.6% and 97.1% of patients, respectively. Fifteen patients (3.0%) suffered new renal and 13 (2.6%) new central nervous system dysfunction. Low pressure or flow during cardiopulmonary bypass, expressed in absolute values or in intensity-duration units, were not predictors of either adverse outcome. Multivariate analysis identified use of postoperative intraaortic balloon counterpulsation (p less than 10(-6], excessive blood loss in the ICU (p less than 10(-4], need for vasopressors before cardiopulmonary bypass (p less than 10(-4], postoperative myocardial infarction (p less than 10(-3], emergency reoperation (p less than 0.002), excessive postoperative transfusion (p less than 0.02), and chronic renal disease (p less than 0.03) as independent predictors of postoperative renal dysfunction. Independent predictors of postoperative central nervous system dysfunction were cardiopulmonary resuscitation in the intensive care unit (p less than 10(-6], intracardiac thrombus or valve calcification (p less than 0.02), and chronic renal disease (p less than 0.03). Age greater than 65 years (40.7% of patients) did not predict either outcome. We conclude that failure of the native circulation during periods other than cardiopulmonary bypass rather than the flows and pressures considered here is the major cause of renal and clinically apparent central nervous system dysfunction after cardiac operations. | 2 |
Window operation: an alternative treatment method for Bartholin gland cysts and abscesses Recently, we developed the "window operation" as a more effective way to treat Bartholin gland cysts and abscesses. The window operation was used to treat 25 Bartholin cysts and 22 Bartholin abscesses during a 3-year period from October 1, 1986 to September 30, 1989. Under local anesthesia, a small piece of skin including the cyst wall was excised in an oval shape, and suturing was performed along the excised margin. Postoperative antibiotics were given in cases of acute inflammation. A new mucocutaneous junction was observed at the 4-week postoperative checkup. No complications or recurrences have been observed during the study period. The window operation can be an alternative method of treatment for Bartholin gland cysts or abscesses. | 0 |
Systemic to pulmonary bronchial blood flow in mitral stenosis. We measured systemic to pulmonary bronchial blood flow [Qbr(s-p)] during total cardiopulmonary bypass in 15 patients with mitral stenosis and elevated pulmonary venous pressure (group A, mean pulmonary wedge pressure = 22.2 +/- 5.4 mm Hg, mean +/- SD) and in 15 patients with coronary artery diseases and normal pulmonary venous pressure (group B). Qbr(s-p) is the volume of blood accumulating in the left side of the heart in the absence of pulmonary and coronary flows. This blood was vented through a cannula introduced into the left atrium and measured. Qbr(s-p) was 76.3 +/- 13.9 ml/min (2.18 +/- 0.37 percent of extracorporeal circulation pump flow) and 22.3 +/- 2.1 (0.63 +/- 0.15) in group A and B, respectively (p less than 0.01). During total cardiopulmonary bypass, pulmonary venous pressure is approximately atmospheric pressure, and no differences in systemic blood pressure, extracorporeal circulation pump flow, and airways pressure were observed between group A and B. Therefore, vascular resistance through the bronchial vessels draining into the pulmonary circulation is reduced in patients with mitral stenosis and elevated pulmonary venous pressure. | 3 |
Radiotherapy. The mainstay in the treatment of early glottic carcinoma. Early squamous cell carcinoma of the glottis may be effectively treated with surgery or radiation therapy. Controversy exists as to whether radiation therapy effects survival at the expense of vocal function by ultimately requiring more total laryngectomies for salvage of local tumor recurrence. This study reviewed the medical records of 185 patients with T1 or T2, NO invasive squamous cell carcinoma of the glottis treated with primary radiation therapy between 1969 and 1984. All patients were followed up for a minimum of 5 years after completion of therapy. One hundred sixty-one patients met the criteria for local control analysis. Radiation therapy controlled disease in 93% (105 of 113) of patients with T1 lesions and 73% (38 of 48) of those with T2 tumors. Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 111 (98%) of 113 and 44 (92%) of 48 patients, respectively. The rate of successful surgical salvage was 75% (T1) and 70% (T2). The T2 lesions with impaired vocal cord mobility or anterior commissure disease were identified as being at increased risk for recurrence after primary radiation therapy. Overall voice preservation was 90%. Our data demonstrate that radiation therapy effects disease-free survival rates that are comparable to those produced by surgery, without sacrificing voice. Although a small percentage of patients with selected early glottic lesions may be more effectively treated with primary conservation surgery, these data do not support a change in philosophy concerning primary treatment of early glottic cancer with radiation therapy. | 0 |
Etoposide in the management of metastatic breast cancer. Etoposide, despite extensive use in other malignancies, has played a minor role in the treatment of patients with breast cancer. Single-agent trials in which etoposide is administered to heavily pretreated patients with metastatic breast cancer have demonstrated a low overall response rate (6.6% of 383 patients), with no convincing evidence for either schedule dependence or a relationship between dose intensity and response. The sole single-agent trial in previously untreated patients suggested that the drug has an approximately 15% response rate in untreated patients. Combination therapy trials in which etoposide has been combined with either cyclophosphamide, doxorubicin, or cisplatin have not yet convincingly demonstrated superiority over any of these drugs as single agents, although cisplatin plus etoposide appears to be superior to either agent alone. In vitro studies suggest that pretreating hormone-sensitive breast cancer cells with estradiol may increase their sensitivity to etoposide-induced DNA cleavage. This may represent a future direction in the use of etoposide in breast cancer. Currently, however, the use of etoposide in breast cancer should be considered investigational. | 0 |
Coronary artery bypass grafting in elderly patients. Comparative results in a consecutive series of 469 patients older than 75 years. A consecutive series of 7104 patients undergoing isolated coronary artery bypass grafting during an 18-year period (1971 to 1988) included 469 patients older than 75 years. Results were analyzed to determine comparative risk factors for morbidity, early and late survival, and functional outcome. Patients younger than 75 years (group I) and patients older than 75 years (group II) were identical for ejection fraction and standard hemodynamic indices. Mean number of grafts and crossclamp time were greater for group II patients (p less than 0.01). Mean age of group I was 58.6 years and group II, 77.6 years (p less than 0.01). Women composed 19.7% (1308/6635) of group I and 36.2% (170/469) of group II patients (p less than 0.05). Mammary grafts were placed in 57.7% (3830/6635) of group I and 41.6% (195/469) of group II patients (p less than 0.05). Overall perioperative mortality rate was 2.1% for group I and 6.8% for group II (p less than 0.05). Perioperative myocardial infarction rate was similar for the two groups. Ventricular and supraventricular arrhythmias, renal insufficiency, neurologic complications, prolonged ventilatory support, increased hospital cost, and prolonged hospitalization were significantly more prevalent (all p less than 0.05) in patients older than 75 years. Five and 10 years postoperatively, there were no significant differences between groups I and II with regard to event-free status including angina, myocardial infarction, and reoperation. The 5-year survival rate was 92% for group I and 80% for group II (p less than 0.05), similar to that of age-matched control subjects. The significantly increased potential for complications and expense of coronary bypass in patients over 75 years of age mandates judicious patient selection and preoperative counseling. Despite a significantly increased early mortality and an anticipated decreased long-term survival paralleling normal life table survival curves, good intermediate functional improvement can be realized in patients older than 75 years, comparable with that expected in a much younger age group. | 3 |
Intravenous but not intracolonic epidermal growth factor maintains colonocyte proliferation in defunctioned rat colorectum. The role of epidermal growth factor in the proliferation of normal and premalignant colonocytes in vivo is not fully understood. In particular, the relative importance of its possible systemic and intraluminal routes of action has not been fully clarified. Rats with surgically defunctioned distal colorectums were used, and mini osmotic pumps were implanted to study the effects of intraluminal and IV administration of epidermal growth factor on colonocyte proliferation. Within 2 weeks of bypass, colonocyte proliferation in defunctioned colorectum has decreased to about one third the rate in normal colorectum or in colorectum proximal to the defunctioning colostomy. Intraluminal epidermal growth factor, infused from the time of operation did not reverse this hypoplasia, whereas IV epidermal growth factor maintained colonocyte proliferation at approximately the normal rate in bypassed colorectum. This model is suitable for testing other putative colonic mitogens for possible intraluminal and systemic effects. | 4 |
Effect of epilepsy and sleep deprivation on the rate of benign epileptiform transients of sleep. Seventy-eight individuals with EEG records containing benign epileptiform transients of sleep (BETS) were identified among 7,400 records reviewed in our laboratory in a 6-year period. The records contained no other abnormality in 51 patients (65%). Genuine epileptiform discharges were found in the records of 19 patients; 14 had a history of epilepsy. Thirty-five patients (45%) had a proven history of epilepsy with antiepileptic drug (AED) therapy. In the records of these patients, the mean number of BETS per unit of time was significantly higher (11.88 +/- 2) than in the record of the rest of the laboratory population with BETS (6.89 +/- 0.9) (p less than 0.02). Among five conventional surface montages, ipsilateral ear referential montage (IERM) showed a significantly higher number of BETS per unit of time than did any other surface montage used in the study. Thirty-nine records (50%) were performed after sleep deprivation (SD). When only IERM was considered, SD records showed a significantly higher number of BETS per unit of time (7.36 +/- 1.1) than did non-SD records (3.89 +/- 0.69) (p less than 0.01). Our findings support the general consensus that individual BETS may be normal variants, but a high occurrence of BETS in the record should raise suspicion of underlying epilepsy. | 2 |
Left ventricular asynchrony in patients with pulmonary hypertension. Left ventricular regional wall motion was evaluated in 11 patients with pulmonary hypertension and 18 control subjects. All 11 patients had secondary pulmonary hypertension and less than 20% measured diameter stenosis in any vessel. This study utilizes a video-intensity-based frame-by-frame computerized technique. All pulmonary hypertensive patients showed early diastolic asynchrony in the anterior or apical regions that lasted 100-200 ms. The size of the abnormal area varied from 2 to 20% of the ventricular silhouette. Four patients also showed systolic abnormalities. No abnormalities were detected in the control group. The cause of the asynchrony detected in pulmonary hypertension is probably due to interventricular interaction caused by pressure gradients across the septum. | 3 |
Incidence of prominent corneal nerves in multiple endocrine neoplasia type 2A. We studied the increased visibility of corneal nerves inside an 8-mm diameter central corneal area in 14 patients with multiple endocrine neoplasia type 2A, one patient with multiple endocrine neoplasia type 2B, five patients with nonhereditary medullary thyroid carcinoma, ten patients with anterior keratoconus, and ten normal subjects. We used a grading system (grade 0 through grade 4) for nerve visibility based on slit-lamp biomicroscopic examination and photographic documentation. All 20 normal eyes showed either grade 0 or grade 1, which indicated no pathologic thickening of corneal nerves. Sixteen of the 28 eyes (57%) with multiple endocrine neoplasia type 2A, however, were evaluated as grade 2 or higher, which indicated thickened corneal nerves. The incidence of high nerve visibility in eyes with multiple endocrine neoplasia type 2A was significantly greater compared to normal eyes (P less than .0001), anterior keratoconus (P less than .0001), and nonhereditary medullary thyroid carcinoma (P = .0012). Furthermore, eight of the 28 eyes (29%) with multiple endocrine neoplasia type 2A showed markedly prominent corneal nerves (grade 3 and 4), a prominence similar to those seen in eyes with multiple endocrine neoplasia type 2B. There was no definite relationship among prominent nerve, age of the patient, and occurrence of pheochromocytoma. These findings suggest that over half of all patients with multiple endocrine neoplasia type 2A show corneal nerves pathologically thickened to different degrees. | 0 |
The surgical management of children with ulcerative colitis. The old vs. the new. The authors' experience with children who have chronic ulcerative colitis was reviewed to compare their current surgical approach (ileoanal anastomosis) with earlier methods of management. Between 1960 and 1984, 137 children with chronic ulcerative colitis underwent surgery (mean duration of follow-up, 7.1 years). In 91 patients, the procedures were a total proctocolectomy with ileostomy or Kock pouch (66) or a lesser colectomy with either an ileostomy (16) or an ileorectal anastomosis (9) (group I). Forty-six patients underwent an ileoanal anastomosis procedure (group II). Children in group I were more likely to have significant preoperative loss of weight, a debilitated condition, and malnutrition. Urgent or emergency surgical intervention was required in 25 percent of patients in group I but in only 4 percent of patients in group II. Trends included 1) a younger age at operation in group II, 2) a higher mortality in group I (7.7 percent) than group II (0 percent), and 3) a higher perioperative mortality with emergency operations (23 percent) than elective procedures (1.6 percent). In group I, 98 percent of patients had an abdominal ostomy, but no patients in group II had an abdominal ostomy. The children with an ileoanal anastomosis had an average of 4.8 stools during waking hours and 1.3 stools each night. On the basis of this experience, the authors recommend use of the ileoanal anastomosis procedure in the surgical treatment of chronic ulcerative colitis in children. | 1 |
Nonfearful panic disorder in neurology patients validated by lactate challenge. OBJECTIVE: Nonfearful panic disorder meets the DSM-III-R criteria for panic disorder but is not associated with subjective fear and anxiety. The authors determined its prevalence in a group of neurology patients and assessed its diagnostic validity as a panic disorder subtype by evaluating the response of the patients with nonfearful panic disorder to sodium lactate and antipanic pharmacotherapy. METHOD: The subjects were all neurology patients referred over 1 year to a university hospital's psychiatric consultation service because of negative medical workups for their symptoms (N = 48). Patients who met the DSM-III-R criteria for panic disorder but did not report subjective anxiety or fear during panic episodes were diagnosed as having nonfearful panic disorder. Afterward, each of those patients received a sodium lactate infusion and, 5 hours later, a sodium chloride infusion. They were then treated with antipanic medication and followed for at least 6 months. RESULTS: Of the 48 neurology patients referred for psychiatric evaluation, 11 (23%) met the criteria for panic disorder, and all 11 met the criteria for nonfearful panic disorder. All 11 responded positively to lactate but not to placebo, and they each experienced an at least 75% reduction in symptoms during the 6-month follow-up period. Detailed case reports of three of these patients are presented. CONCLUSIONS: These findings support the construct and predictive diagnostic validity of nonfearful panic disorder as a subtype of panic disorder and suggest that a lack of attention to this group leads to both the underestimation of the prevalence of panic disorder and to the withholding of potentially successful treatments for this group. | 2 |
Anomalies of intestinal rotation in childhood: analysis of 447 cases. This report concerns 447 infants and children with anomalies of rotation and fixation. Patients were placed in four groups based on initial symptoms. Group A involved 18 patients with acute midgut volvulus. At laparotomy, midgut volvulus was noted and reduction of midgut volvulus and a Ladd procedure were performed in 10 cases and resection was required in 8. There were five deaths (28%). Group B included 54 children with chronic symptoms of intermittent volvulus or duodenal obstruction. Group C involved 44 cases of malrotation observed during exploration for other disorders. Patients in groups B and C underwent a Ladd procedure and appendectomy. There were five unrelated deaths. Group D included 331 neonates with malrotation caused by either diaphragmatic hernia (n = 111) or abdominal wall defects (n = 220). A Ladd procedure was performed on 48 patients with abdominal wall defects and 29 surviving children with diaphragmatic hernia. Only 2 of 172 (1.2%) patients with abdominal wall defects and 1 of 34 (2.9%) patients with diaphragmatic hernia not treated for malrotation had midgut volvulus. Midgut volvulus is more common in infants and is associated with a high mortality rate (28%). Patients with malrotation and chronic obstructive symptoms or those observed during other elective procedures should undergo a Ladd procedure because of the risk of midgut volvulus. The risk of midgut volvulus is low in patients with abdominal wall defects and, probably as a result of adhesions from previous neonatal operations. | 4 |
The case for porous-coated hip implants. The femoral side. A series of 1163 total hip arthroplasties (THAs) using porous-coated femoral components were roentgenographically assessed for implant fixation. For 959 primary THAs followed from two to 12 years, the femoral revision rate was 1% and the ten-year survivorship rate was 96.4%; 150 young patients had a fixation failure incidence of only 1.3% at a mean follow-up period of 6.4 years; in 204 revision THAs, the femoral re-revision rate was 4% at a mean follow-up period of 53.4 months. Failures were largely related to inadequate femoral canal filling. Because of refinements in implant design and surgical techniques, a press fit of the implant is currently achieved in 94% of cases compared to 36% during the first five years. Porous-coated femoral components have yielded results equivalent to those with cement in primary THAs. Excellent results were observed in relatively young patients and patients with revisions. | 4 |
Gastrointestinal intraluminal pH in normal subjects and those with colorectal adenoma or carcinoma. Recent evidence suggests that the production of colorectal carcinogens is facilitated when the pH of the colonic contents is alkaline. It follows that the colonic intraluminal pH of patients with colorectal neoplasms should be higher than in normal subjects. Gastrointestinal pH has been measured in 30 patients with colorectal cancer and 37 patients with benign colorectal adenomas (using a pH sensitive radiotelemetry capsule). These values have been compared with those recorded in 66 normal subjects. No differences in gastrointestinal pH were found and the results did not support the hypothesis that colonic pH plays a role in the aetiology of colorectal neoplasia. | 0 |
Angiotropic intravascular large-cell lymphoma (malignant angioendotheliomatosis): report of a case and review of the literature. We present a case of angiotropic large-cell lymphoma and review the literature in order to define the neurologic features of this rare disorder. This is the first report of gadolinium-DTPA imaging in angiotropic large-cell lymphoma that demonstrates infarcts of multiple ages, as well as striking meningeal enhancement. Angiotropic large-cell lymphoma should be suspected in patients with clinical evidence of small and large cerebral vessel disease and diagnosis requires skin, liver, renal, meningeal, or brain biopsy. Single modality treatment, using either radiation therapy or steroids, has been ineffective, and new findings of a lymphomatous origin of this neoplasm suggest that combination chemotherapy may be indicated. | 2 |
Cytomegalovirus colitis and wasting. Disseminated cytomegalovirus (CMV) infection is associated with significant and progressive depletion of body cell mass and body fat in patients with the acquired immune deficiency syndrome (AIDS). In a study examining the effect of ganciclovir on wasting in AIDS patients with disseminated CMV infection, it was found that patients receiving ganciclovir had significant improvement in such variables as body cell mass, body fat, body weight, and total body energy content when compared with those not receiving ganciclovir. The repletion of body cell mass observed in AIDS patients with disseminated CMV infection who are successfully treated with ganciclovir appears to be associated with improved quality of life and prolongation of survival. | 1 |
Bronchiolar morphology after systemic arterial interruption. To assess ischemic lesions as a factor in obliterative bronchiolitis after lung transplantation, the authors severed the left bronchial arteries of 15 dogs, together with the left stem bronchus, the latter being immediately reanostomosed. They examined the bronchioles at weekly interfals up to three and a half months. On the week chosen each dog was anesthetized, totally heparinized, and exsanguino-perfused with saline. Just after heart arrest, the thoracic aorta was injected with a barium solution until this white medium appeared in the bronchial arteries. The heart-lung blocs were excised en bloc, submitted to soft-tissue x ray, fixed, and then sliced to 1 cm. Corresponding right and left 5-mm-thick samples of these slices were prepared for contact microradiography followed by histologic 5-to-20-micron-thick, stained, correlated specimens. For two weeks the left bronchial arteries remained empty, but there was no necrosis or edema. Between two and four weeks barium solution appeared in the bronchial arteries, and the bronchiolar epithelium had become multistratified. Later the left bronchiangiogram became similar to the right, but there were more folds of the mucosa and a little submucosal fibrosis. These studies provide proof that no significant ischemic lesions occurred during repermeation of the bronchiolar vascular bed. Ischemia, if existent, is not a significant factor in obliterative bronchiolitis. | 3 |
Collateral circulation in Kawasaki disease with coronary occlusion or severe stenosis. Forty patients with Kawasaki disease with severe coronary sequelae were investigated. All had at least a 90% reduction in the diameter of the major coronary artery. Collateral vessels were seen in 32 of 33 (97%) patients with total occlusion. All patients with severe stenosis but not total occlusion had no or poorly developed collateral vessels. Analysis according to the presence or absence of collateral vessels showed no significant differences in the results of treadmill stress testing and myocardial imaging between these two groups. In patients treated surgically, the abnormalities recognized by these tests were normalized or improved when the bypass was patent. These data indicate that collateral circulation in patients with Kawasaki disease cannot be seen angiographically unless there is total occlusion and the presence of collateral circulation cannot provide protection against stress-induced myocardial ischemia. | 3 |
Primary papillary carcinoma of a thyroglossal duct cyst: report of a case and literature review. Thyroglossal duct cysts are the most common anomaly in thyroid development. They are twice as frequent as branchial cleft abnormalities and, in children, are second only to enlarged cervical lymph nodes as the cause of neck mass. Generally, duct cysts are benign, but 1 per cent of cases may be malignant. From the world literature, 114 cases of malignant thyroglossal cysts were available for review. With the addition of our own case, we discuss 115 instances of duct cysts. The different types of neoplasia described included thyroid papillary carcinoma in 81.7 per cent, mixed papillary-follicular carcinoma in 6.9 per cent, squamous cell carcinoma in 5.2 per cent, follicular and adenocarcinoma in 1.7 per cent each, and malignant struma, epidermoid carcinoma and anaplastic carcinoma in 0.9 per cent each. Of the 115 cases surveyed, 35 thyroid glands were examined microscopically; of these, four (11.4 per cent) contained malignant foci. Whether these are primary malignancies of the thyroglossal duct cysts or metastases is discussed. | 0 |
Anti-GM1 IgM antibodies in motor neuron disease and neuropathy. We found anti-GM1 IgM antibodies in 23% of 56 patients with motor neuron disease (MND), in 19% of 69 patients with neuropathy, and in 7% of 107 controls with other neurologic and nonneurologic diseases. Most of these patients had anti-GM1 IgM antibody titers of 1:80 or less; slightly higher antibody titers (up to 1:640) were found in 3 patients, 1 with MND and 2 with neuropathy, and very high titers (1:20,480) in a patient with MND and an IgM kappa M protein that reacted with GM1, GD1b, and asialo GM1. Six other patients with anti-GM1 IgM that also bound to GD1b. Reactivity with GD1b did not correlate with anti-GM1 titers but was only present in patients with MND or neuropathy. Anti-GM1 IgM antibodies may be a normal constituent of the human antibody repertoire but their frequency and, in some cases, their levels are higher in patients with MND and neuropathy. The origin and the pathogenetic role of these antibodies in neural impairment remain to be established. | 2 |
Translumbar arch aortography: a retrospective controlled study of usefulness, technique, and safety. Subclavian and axillary artery stenoses may lead to axillofemoral bypass graft failure. These arteries were assessed preoperatively with arch aortography performed after conventional high translumbar peripheral aortography by exchanging the initial 16-gauge sheath for a 5-F pigtail catheter. Thirty-two diagnostic translumbar runoff and arch (TLR-arch) aortograms were obtained in 30 patients with advanced lower extremity ischemia. In six patients (20%), the results of the arch study influenced the choice of an inflow site. These patients were compared with 70 control subjects who underwent conventional translumbar aortography without arch studies. In the TLR-arch group, two major complications occurred in one patient, while in the control group 11 major complications occurred in 10 patients. One retroperitoneal hematoma occurred in the TLR-arch group; two occurred in the control group. The mean change in hematocrit for the TLR-arch group was -3.81% (-0.0381), and for the control group it was -4.17% (-0.0417). This difference was not statistically significant. Arch aortography is a valuable adjunct to the translumbar aortofemoral study. It can be simply performed without increasing the morbidity of the peripheral study. | 4 |
Biomechanical evaluation of lumbar spinal stability after graded facetectomies. In an in vitro experiment using fresh human lumbar functional spinal units, the effects of the division of the posterior ligaments (consisting of the supraspinous/interspinous ligaments) and graded facetectomies were investigated. The graded facetectomies consisted of unilateral and bilateral medial facetectomies, and unilateral and bilateral total facetectomies. Six kinds of moments were applied and ranges of motion (ROM) and neutral zones (NZ) were determined three-dimensionally by stereophotogrammetric methods. Range of motion was not affected by the division of the supraspinous/interspinous ligaments for all load modes. In flexion, ROM increased slightly after unilateral medial facetectomy. In right axial rotation, ROM increased after left unilateral total facetectomy. Range of motion was not affected, even by bilateral total facetectomies, in extension and lateral bendings. This study suggested that medial facetectomy does not affect lumbar spinal stability, and conversely, total facetectomy, even created unilaterally, makes the lumbar spine unstable. | 4 |
Differences in health status between older and younger homeless adults. The Institute of Medicine has placed a priority on determining the special health-care needs of elderly homeless persons. As part of a community-based study of 521 homeless adults in two beach communities of Los Angeles, we compared the demographic characteristics and health of older (age rangek 50-78, n = 61) and younger (age range, 18-49, n = 460) homeless individuals. Compared with younger adults, older adults were more likely to be white (85% versus 61%), veterans (59% versus 27%), retired (36% versus 3%), and living in a vehicle (21% versus 8%). Older adults were more likely to report having a chronic disease (69% versus 49%), functional disabilities, no informal social contacts during the previous month (49% versus 27%), observed high blood pressure (42% versus 22%), elevated creatinine (11% versus 2%), and elevated cholesterol (57% versus 36%). Older adults were less likely to have a toothache (3% versus 30%), report psychotic symptoms (25% versus 42%), and to be illegal drug users (15% versus 55%). Although they are chronologically younger, the constellation of health and functional problems of older homeless adults resemble those of geriatric persons in the general population. We suggest that geriatricians could play a significant role in training other primary-care providers to evaluate and treat socially isolated older homeless adults in a more comprehensive way than is currently standard in practice (e.g., interdisciplinary team care and emphasis on functional status, rehabilitative medicine, and assessment for sensory impairment). | 4 |
Upper gastrointestinal bleeding in relation to previous use of analgesics and non-steroidal anti-inflammatory drugs. Catalan Countries Study on Upper Gastrointestinal Bleeding To assess the risk of upper gastrointestinal bleeding associated with the use of individual non-narcotic analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), a multicentre study of 875 cases of upper gastrointestinal bleeding and 2682 hospital controls was done. With control for confounding factors, the overall odds ratio estimate for aspirin taken at least once during the week before the first symptom was 7.2 (95% confidence interval 5.4-9.6). Non-aspirin NSAIDs associated with upper gastrointestinal bleeding were diclofenac (7.9 [4.3-14.6]), indomethacin (4.9 [2.0-12.2]), naproxen (6.5 [2.2-19.6]), and piroxicam (19.1 [8.2-44.3]). Paracetamol, propyphenazone, and dipyrone did not increase the risk. A previous history of gastrointestinal bleeding or peptic ulcer did not greatly affect odds ratio estimates, which differed according to sex and were higher for younger than for older patients. However, the incidence of upper gastrointestinal bleeding was higher among the elderly. | 4 |
Lactation following conservation surgery and radiotherapy for breast cancer. A 38-year-old woman with early stage invasive breast cancer was treated with wide excision of the tumor, axillary lymph node dissection, and breast irradiation. Three years later, she gave birth to a normal baby. She attempted breast feeding and had full lactation from the untreated breast. The irradiated breast underwent only minor changes during pregnancy and postpartum but produced small amounts of colostrum and milk for 2 weeks postpartum. There are only a few reports of lactation after breast irradiation. These cases are reviewed, and possible factors affecting breast function after radiotherapy are discussed. Because of scant information available regarding its safety for the infant, nursing from the irradiated breast is not recommended. | 0 |
Infections in HIV-infected travelers: risks and prevention. OBJECTIVE: To review risks for infection and to outline strategies to protect the health of travelers infected with human immunodeficiency virus (HIV). DATA SOURCES: Original reports and summaries of the geographic distribution and frequency of infections as well as of special risks these infections impose on HIV-infected persons. The recommendations incorporate guidelines published by the Centers for Disease Control (CDC) and the World Health Organization. STUDY SELECTION: Sources containing the most recent, pertinent information. DATA SYNTHESIS: Infections of the gastrointestinal tract are common in all travelers to developing countries and are likely to be more frequent, severe, and difficult to treat in HIV-infected persons. Prominent among the respiratory tract infections that pose special risks to HIV-infected travelers are influenza, measles, and fungal infections with geographically focal distributions. The most common vector-borne infection, malaria, appears to present relatively little, if any, incremental risk to the HIV-infected traveler. Persons with HIV infection respond less vigorously to vaccines and have a higher frequency of adverse reactions to antimicrobial agents. Nevertheless, immunizations and chemoprophylaxis can reduce the risk for many travel-related infections. Additionally, there are protective measures that travelers can take to minimize exposure to pathogens. CONCLUSIONS: By understanding the risks for disease in different destinations, assessing patients' HIV status, counseling patients about travel plans and personal protective measures, appropriately using vaccines and chemoprophylaxis, as well as instituting early treatment of infection, physicians can help HIV-infected patients to preserve their health during travel. | 1 |
Vascular lesions of the intestines. This article reviews the pathology, pathophysiology, diagnosis, and treatment of vascular lesions of the intestine as a cause of gastrointestinal bleeding. In addition, a modified system for classifying such lesions, based on the author's personal experience with such lesions, is presented. | 4 |
Gastric infarction. We have described a patient with an acute condition of the abdomen who had infarction of the stomach and the small intestine due to atheromatous thrombus of celiac and superior mesenteric arteries. We believe this unusual simultaneous occurrence of gastric and small intestinal infarction is coincidental. The outcome of gastric infarction is frequently fatal. | 4 |
Are myotonias and periodic paralyses associated with susceptibility to malignant hyperthermia? Excised muscles from patients with myotonia or periodic paralysis were subjected to the in vitro contracture test for susceptibility to malignant hyperthermia (MH). In a group of 44 patients, this standard test gave four positive, 10 equivocal and 30 negative results. The results for 27 control muscles from normal subjects were negative. When the test was performed with less than normal concentrations of contracture-triggering substances (caffeine less than or equal to 2 mmol litre-1, less than or equal to 2% halothane), 70% of the muscles from the patients and only 15% of the controls responded with small contractures (less than 0.2 g). These results should not be taken to indicate that the patients have the genetic trait for MH. The positive and equivocal test results, in addition to the slight contractures, may be accounted for by the electrical after-activity in the cases of pure myotonia, and by increased resting myoplasmic [Ca2+] in myotonic dystrophy. This shows that the in vitro contracture test lacks specificity. | 2 |
Predictors of long-term cardiac survival in patients with multivessel coronary artery disease undergoing percutaneous transluminal coronary angioplasty. The predictors of 5-year cardiac survival in patients with multivessel coronary artery disease (CAD) undergoing percutaneous transluminal coronary angioplasty (PTCA) were analyzed in a series of 637 consecutive patients. The average age was 59 +/- 11 years in 472 men and 165 women. Diabetes mellitus, previous myocardial infarction and unstable angina were present in 119 (19%), 261 (41%) and 305 (47%) patients, respectively. Angiographically, 460 patients had 2-vessel and 177 patients had 3-vessel CAD. The left ventricular contraction score was greater than or equal to 12 in 55 patients. Angiographic success (less than 50% residual stenosis) was achieved in 85% of the 1,343 narrowings and clinical success was obtained in 526 (83%) of the 637 patients. Complete revascularization was obtained in 177 (34%) of 526 successful patients. Procedure-related complications resulted in death in 9 patients (1.4%), in Q-wave myocardial infarction only in 6 patients (0.9%) and in emergency bypass surgery in 44 patients (6.9%) (of whom 10 had Q-wave myocardial infarction). Follow-up for greater than or equal to 1 year and up to 6 years after PTCA was obtained in 608 (95%) of the 637 patients. To determine the predictors of 5-year cardiac survival, 28 clinical, angiographic and procedural variables were analyzed by Cox proportional-hazards regression. The estimated 5-year survival after PTCA was 88 +/- 2% in successful patients and 77 +/- 5% in patients in whom PTCA was unsuccessful (p less than 0.001). When clinical success was forced into the Cox regression, the left ventricular contraction score of greater than or equal to 12, diabetes mellitus and age greater than or equal to 65 years showed additional adverse effects on survival. | 3 |
Basal cell-specific and hyperproliferation-related keratins in human breast cancer. In normal breast tissue and in noninvasive breast carcinomas, various keratin-14 antibodies were reactive predominantly with the basal/myoepithelial cell layer, although mainly in terminal and larger ducts luminal cells sometimes also were stained. A similar reaction pattern was found with an antibody directed against keratin 17, although this antibody was more often found negative than keratin 14 in the pre-existing myoepithelial cells in intraductal carcinomas. Furthermore antibodies reactive with hyperproliferation-related keratins 6 and 16 were used. One of these (LL025) was completely negative in normal breast tissue and noninvasive breast carcinomas. However 10% of the invasive carcinomas were diffusely or focally positive with this latter antibody, while in 18 of 115 cases of invasive breast carcinomas studied, a basal cell phenotype was detected. A relatively high concordance was found between the carcinomas immunostaining with the basal cell and the hyperproliferation-related keratins, but not between these markers and the proliferation marker Ki-67. This supports the conclusion that basal cells in breast cancer may show extensive proliferation, and that absence of Ki-67 staining does not mean that (tumor) cells are not proliferating. | 0 |
Prospective study of early detection of hepatocellular carcinoma in patients with cirrhosis. We prospectively monitored 140 cirrhotic patients for the development of hepatocellular carcinoma for 6 yr, using periodical screening by high-resolution convex-array ultrasonography and alpha-fetoprotein. Twenty-eight patients were positive for HBs antigen, 26 patients had received blood transfusions and were negative for HBs antigen and 26 patients had a history of heavy drinking. We detected hepatocellular carcinoma in 40 patients during this period. The overall cumulative incidence of hepatocellular carcinoma in the 6 yr was 39%; the cumulative incidence was 59% in patients with HBsAg, 53% in patients who had had blood transfusions and were negative for HBsAg and 22% in patients who had a history of heavy drinking and who were without HBsAg. Detection of the carcinoma in 85% of these 40 patients was based on results of ultrasonography. Twenty-six of the patients (65%) had a small hepatocellular carcinoma of 2 cm or less. alpha-Fetoprotein levels were lower than 100 ng/ml in 56% of these 40 patients. Patients with cirrhosis are at high risk of developing hepatocellular carcinoma, especially patients with HBsAg or with a history of blood transfusion who are negative for HBsAg. Periodic monitoring by use of ultrasonography in particular is recommended for early detection of hepatocellular carcinoma. | 0 |
Hemolysis due to branch pulmonary stenosis after the arterial switch procedure. An infant with d-transposition of the great arteries underwent arterial switch operation using the modified Jatene technique. Severe bilateral branch pulmonary artery stenosis and mechanical hemolysis subsequently developed. The hemolysis resolved after surgical repair of the stenotic arteries. Probable causes are discussed. | 3 |
Morbidity associated with incompletely erupted third molars in the line of mandibular fractures. A retrospective analysis of 105 mandibular fractures associated with incompletely erupted third molars was undertaken. It was found that there was no difference in the rates of complication if the teeth were retained or extracted, or if an open or closed reduction was performed. The combination of tooth retention with open reduction, however, shows a trend toward being the treatment most prone to postoperative complications. | 4 |
Primary invasive carcinoma of the vagina. A retrospective review was conducted of 53 women with invasive carcinoma of the vagina and without documented exposure to diethylstilbestrol who were seen at the University of California Irvine Medical Center, Long Beach Memorial Medical Center, and Saddleback Memorial Medical Center from 1976-1988. Forty-seven (89%) had squamous cell carcinoma and six (11%) adenocarcinoma. Thirty-seven (70%) were treated with whole-pelvis irradiation and brachytherapy, nine with surgery alone, and the other seven with a combination of treatments. The crude and corrected 2-year survival rates for the entire group were 47 and 69%, respectively. Those with previous pelvic surgery were more likely to develop serious treatment-related complications. There was a statistically significant correlation between previous hysterectomy and the diagnosis of primary invasive carcinoma of the vagina after the onset of symptoms. Women diagnosed during routine examination, before symptom onset, tended to have a survival advantage. All women, including those who have had hysterectomy, should be counseled to continue gynecologic cancer surveillance regardless of age. | 0 |
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